CDI Specialist: Elevate Clinical Documentation Quality

Cayuga Health, A Member of Centralus Health; Town of Ithaca (NY); On-site; USD 85,000 - 110,000; Full time

Job summary

Cayuga Health, a member of Centralus Health, seeks a CDI Specialist to collaborate with physicians, nursing, HIM, coding and billing to improve documentation quality and support appropriate ICD-10 coding in alignment with CMS and regulatory agencies.

The CDI Specialist will query providers to clarify gaps in documentation and ensure quality and compliance, balancing patient care with cost efficiency and revenue optimization.

Qualifications

• Bachelor's degree in nursing preferred; or an Associate's degree with 3–5 years inpatient clinical experience.
• CCDS, CDIP, CCS, CCS-P, or CPC certification preferred.
• Strong verbal and written communication, organizational and problem-solving skills.

Responsibilities

• Promote Cayuga Health System's mission, vision and values.
• Assess clinical documentation to reflect level of service and severity of illness per requirements.
• Follow-up evaluation of documentation to ensure issues are recorded in the medical record.
• Identify gaps in provider documentation; manage queries and responses.
• Recommend refinement of principal diagnosis to facilitate appropriate DRG assignment.
• Participate in provider education to promote accurate, complete documentation per guidelines.
• Demonstrate knowledge of HIM coding standards and apply to ongoing documentation evaluation.
• Participate in denial management for DRG adjustments and medical necessity denials.
• Maintain knowledge of regulatory requirements for utilization practices and Medicare/Medicaid processes.
• Share knowledge with coworkers and contribute to continuous improvement.
• Review regulatory reports to identify actions to maximize reimbursement and minimize risk.
• Attend team meetings and maintain professional appearance and punctuality.
• Maintain patient confidentiality in quality care.
• Be flexible in assuming other appropriate responsibilities.

Skills

Communication

Collaboration

Problem-solving

Education

BSN preferred

Associates with 3–5 years inpatient experience

CCDS/CDIP/CCS/CCS-P/CPC certification preferred

Job description

Cayuga Health, a member of Centralus Health, seeks a CDI Specialist to collaborate with physicians, nursing, HIM, coding and billing to improve documentation quality and support appropriate ICD-10 coding in alignment with CMS and regulatory agencies.

The CDI Specialist will query providers to clarify gaps in documentation and ensure quality and compliance, balancing patient care with cost efficiency and revenue optimization.