Description

SENIOR CLINICAL DOCUMENTATION SPECIALIST (CDI)

WHAT YOU'LL DO

Conduct comprehensive reviews of inpatient medical records

Identify clinical documentation gaps and opportunities for clarification

Develop and issue compliant physician queries

Evaluate clinical indicators, diagnoses, procedures, SOI/ROM and CC/MCC opportunities

Support accurate ICD-10-CM/PCS and DRG assignment

Collaborate with physicians, coders, clinical teams and other healthcare stakeholders

Monitor CDI quality, productivity and query performance metrics

Provide guidance and mentoring to CDI Specialists

Participate in audits, quality improvement and CDI program initiatives

Ensure adherence to AHIMA, ACDIS, CMS and organizational CDI standards

Requirements

QUALIFICATIONS

PHRN/USRN license.
Minimum 3 years’ clinical experience preferably in critical care/emergency setting.
Will consider candidates with 4+years’ clinical experience in non-critical care acute care settings.
Prefer candidates with IP CDI experience.
Strong knowledge of ICD-10-CM/PCS, DRGs, CC/MCCs, SOI and ROM.
Demonstrated experience with physician queries and documentation clarification.
Strong clinical judgment and analytical skills.
Excellent written and verbal English communication.
Experience with Epic or other major EHR platforms preferred.
CDI certification such as CDIP, CCDS, or CIC is highly preferred.