Clinical Documentation Improvement (CDI) Specialist

The Department of Health Information Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Clinical Documentation Improvement (CDI) Specialist.

Job Summary

Reporting to the CDI Manager and Director of Health Information Management, the CDI Specialist is responsible for reviewing inpatient medical records to ensure that clinical documentation accurately and comprehensively reflects the patient's clinical condition, severity of illness, risk of mortality, and services provided throughout hospitalization.

Working collaboratively with physicians, residents, advanced practice providers, nursing staff, coding professionals, and other interdisciplinary healthcare teams, the CDI Specialist identifies opportunities for documentation clarification and improvement to support accurate clinical coding, appropriate reimbursement, regulatory compliance, and quality reporting.

Key Responsibilities and Duties

• Conduct concurrent reviews of inpatient medical records upon admission and throughout hospitalization for designated patient and payer populations, including Medicare, Medicaid, and commercial insurance.
• Evaluate clinical documentation for accuracy, completeness, specificity, and consistency with the patient's clinical presentation, treatment, and care.
• Identify documentation gaps, inconsistencies, or opportunities for clarification related to diagnoses, comorbidities, complications, severity of illness, and risk of mortality.
• Communicate with attending physicians, residents, advanced practice providers, and other clinical staff to obtain timely clarification of clinical documentation through appropriate verbal and written queries.
• Collaborate with Health Information Management coding professionals to ensure that principal diagnoses, secondary diagnoses, and relevant comorbidities are accurately and completely documented.
• Apply clinical knowledge, critical thinking, and analytical reasoning to assess medical records and identify documentation improvement opportunities.
• Support accurate clinical coding, quality reporting, and reimbursement through improved documentation practices and an understanding of applicable coding and Medicare reimbursement methodologies.
• Develop and deliver formal and informal education to physicians, nursing staff, and other clinical providers regarding clinical documentation requirements, best practices, and identified improvement opportunities.
• Collaborate with physician leadership and departmental stakeholders to develop tools, educational resources, and processes that support consistent and effective clinical documentation.
• Conduct timely follow-up with providers regarding outstanding documentation clarification requests and ensure appropriate resolution.
• Participate in departmental and organizational quality improvement initiatives designed to strengthen documentation accuracy, clinical data integrity, and operational efficiency.
• Maintain effective working relationships with physicians, nursing leadership, coding professionals, and interdisciplinary healthcare teams to promote a collaborative documentation improvement environment.
• Utilize electronic medical records, CDI applications, and Microsoft Office applications to perform documentation reviews, communicate findings, and support departmental activities.
• Maintain the confidentiality and security of patient information in accordance with HIPAA, institutional policies, and applicable regulatory requirements.
• Maintain professional competency through continuing education, professional development, and participation in relevant training programs.
• Demonstrate professionalism, accountability, cultural competence, and adherence to SUNY Downstate's institutional mission, values, and standards of conduct.
• Perform other related duties as assigned.

Reporting to the CDI Manager and Director of Health Information Management. Excellent interpersonal skills.  Including verbal and written communication, to develop relationships necessary to influence physician document process.  Ability to prioritize and be self directed and capable of independent decision making. Analytic skills necessary to clinically assess medical records.  Critical thinking, problem solving and deductive reasoning skills.  Ability to organize and present information clearly and concisely.  Basic computer skills including Microsoft products Office, Excel and PowerPoint. Working knowledge of Medicare reimbursement and coding structures. The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to facilitate clinical documentation that accurately reflects the patients' severity of illness and risk of mortality by improving the quality of the physicians' clinical documentation.  This involves extensive record review, interaction with physicians, residents, advanced practice nurses, ancillary providers, coding and HIM professionals and nursing staff. Key Competencies include: Foundational Thinking Skills: Reviews inpatient medical records for identified payer populations (Medicare, Medicaid, Blue Cross/Blue Shield, and others as designated) as directed on admission and throughout hospitalization. Strategic Management: In collaboration with physician leadership, designs and implements specific tools to support medical record physician documentation. Human Resources Leadership Skills: Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff. Relationship Management: Communicates with attending physician and other relevant clinical staff, either verbally or through written methodology. Personal and Professional Accountability: Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution. Career Planning: Assures personal and professional growth through self-study/attendance/participation in seminars and workshops. Fostering Professional Environment: Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to the Medical Center. Optimizing the Leader within/Reflective Practice Behaviors: Behaves in accordance with Mission, Vision, and Values of the Medical Center. Demonstrates integrity, truthfulness and fairness when working with others. Creates an environment of acceptance and respect in the work place. Cultural Competence: Integrates knowledge of cultural competence and inclusion in all daily practices such as assessment, documentation, communication, etc. Shared Decision Making: Works closely with HIM coding staff to assure documentation of discharge diagnosis (es) and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care.  Performance Improvement: Contributes to organizational, departmental and unit based process improvement activities. Technology: Demonstrates and maintains competency and accuracy in use of software applications including capability in Microsoft Office applications. Clinical Practice Knowledge and Skill: Conducts daily follow-up communication with providers regarding existing clarifications to obtain needed documentation specificity. 

Required Qualifications

• Must meet one of the following educational and professional credential requirements:
  • Registered Nurse pathway: Current, active New York State Registered Nurse license, with a minimum of three (3) years of acute care nursing experience; OR
  • Physician education pathway: Doctor of Osteopathic Medicine (DO), Bachelor of Medicine/Bachelor of Surgery (MBBS), or equivalent medical degree from a recognized medical institution, including international medical graduates.
• Minimum of two (2) years of professional experience in Clinical Documentation Improvement (CDI) or Clinical Documentation Integrity, including inpatient medical record review and clinical documentation clarification.
• Demonstrated knowledge of clinical documentation standards, medical terminology, disease processes, and inpatient clinical care.
• Working knowledge of Medicare reimbursement methodologies, clinical coding structures, and the relationship between clinical documentation, coding accuracy, and reimbursement.
• Strong clinical assessment, analytical reasoning, critical thinking, and problem-solving skills.
• Excellent written, verbal, and interpersonal communication skills, including the ability to collaborate effectively with physicians and interdisciplinary healthcare professionals.
• Ability to work independently, manage competing priorities, exercise sound professional judgment, and maintain accuracy and attention to detail.
• Proficiency with Microsoft Office applications, including Word, Excel, and PowerPoint.
• Or, a satisfactory equivalent combination of experience, education and training. 

Preferred Qualifications

• Three (3) or more years of Clinical Documentation Improvement experience in an acute care hospital setting.
• Certified Clinical Documentation Specialist (CCDS) certification through the Association of Clinical Documentation Integrity Specialists (ACDIS) or Certified Documentation Integrity Practitioner (CDIP) certification through the American Health Information Management Association (AHIMA).
• Experience working in an academic medical center, teaching hospital, or complex inpatient healthcare environment.
• Familiarity with ICD-10-CM/PCS coding, Medicare Severity Diagnosis Related Groups (MS-DRGs), severity of illness (SOI), and risk of mortality (ROM) methodologies.
• Experience with electronic health records and clinical documentation improvement software.
• Experience providing physician education, clinical documentation training, or participating in documentation-related performance improvement initiatives.