CDI Specialist: Elevate Documentation & Coding Quality

Next Move Healthcare; City of White Plains (NY); On-site; USD 1,000 - 143,000; Full time

Benefits offered by this job

Competitive salary based on experience

Health and wellness benefits

Retirement plan

Paid time off

Professional development opportunities

Career growth in CDI and healthcare

Job stability at healthcare provider

Job summary

Next Move Healthcare in White Plains, NY is seeking an experienced Clinical Documentation Improvement Specialist (CDIS) to support accurate documentation across the medical record. The role involves concurrent and post-discharge chart reviews, identifying documentation opportunities and collaborating with physicians and coding professionals.

The ideal candidate has a strong adult acute-care background, in-depth knowledge of disease processes, coding guidelines, DRG assignment, severity of

Qualifications

• BSN or Bachelor's degree is required.
• Approximately 5 years of adult acute-care clinical experience in Medical-Surgical, Critical Care/ICU, ED, or PACU.
• Strong knowledge of pathophysiology, disease processes, and coding guidelines.
• Understanding of DRG assignment and clinical documentation requirements.
• Excellent written and verbal communication and problem-solving skills.

Responsibilities

• Review inpatient medical records for completeness, accuracy, severity of illness, and quality.
• Perform initial and concurrent clinical documentation reviews.
• Identify opportunities to improve documentation and reflect the patient’s clinical condition.
• Ensure documentation supports proper diagnosis coding and level of care.
• Develop physician queries and documentation clarification requests.
• Query providers about principal diagnosis, comorbidities, severity of illness, and quality measures.
• Follow up on outstanding documentation queries and ensure timely resolution.
• Collaborate with physicians, APPs, coders, nurses, and care-team members.
• Partner with Health Information Management and coding teams to resolve discrepancies.

Skills

Clinical documentation

Analytical thinking

Communication skills

Team collaboration

Education

BSN or Bachelor’s degree

Tools

CDI software

Electronic Medical Records

Windows-based software

Job description

Next Move Healthcare in White Plains, NY is seeking an experienced Clinical Documentation Improvement Specialist (CDIS) to support accurate documentation across the medical record. The role involves concurrent and post-discharge chart reviews, identifying documentation opportunities and collaborating with physicians and coding professionals.

The ideal candidate has a strong adult acute-care background, in-depth knowledge of disease processes, coding guidelines, DRG assignment, severity of