CDI Specialist: Elevate Clinical Documentation & Quality

Palestine Regional Medical Center; Palestine (TX); On-site; USD 60,000 - 80,000; Full time

Job summary

Palestine Regional Medical Center, located in Palestine, TX, is seeking a Clinical Documentation Integrity (CDI) Specialist to enhance the quality and accuracy of clinical documentation. This role involves concurrent reviews, educating healthcare staff, and ensuring compliance with coding regulations.

The ideal candidate will have at least 3 years of clinical experience, hold an Associate’s Degree in a relevant healthcare field, and possess strong skills in collaboration and communication. Opportunities for career growth and development in a supportive environment are emphasized.

Qualifications

• 3+ years clinical experience in inpatient care or case management.
• Experience with CDI, ICD-10-CM/PCS, and coding guidelines.
• Required certifications licensed as a Nurse or Health Information Administrator.

Responsibilities

• Perform concurrent reviews of inpatient records.
• Educate staff on documentation best practices.
• Collaborate with various healthcare teams.
• Maintain knowledge of CMS regulations and industry guidelines.

Skills

Detailed understanding of coding systems (ICD-10, MS-DRG)

Excellent written and verbal communication

Ability to engage interdisciplinary teams

Proficient in EMR systems and analytics

Strong attention to detail and organizational skills

Education

Associate’s Degree in nursing or health information management

Bachelor’s Degree in nursing or health information management (Preferred)

Master’s Degree in nursing or health information management (Preferred)

Job description

Palestine Regional Medical Center, located in Palestine, TX, is seeking a Clinical Documentation Integrity (CDI) Specialist to enhance the quality and accuracy of clinical documentation. This role involves concurrent reviews, educating healthcare staff, and ensuring compliance with coding regulations.

The ideal candidate will have at least 3 years of clinical experience, hold an Associate’s Degree in a relevant healthcare field, and possess strong skills in collaboration and communication. Opportunities for career growth and development in a supportive environment are emphasized.