CDI Specialist: Elevate Documentation & Patient Care

Catholic Health Services; Melville, Northern (NY, KY); Hybrid; USD 105,000 - 150,000; Full time

Job summary

Catholic Health Services seeks a Clinical Documentation Integrity Specialist to perform concurrent reviews of inpatient records, identify missing diagnoses, and facilitate physician queries for accurate documentation.

Collaborating with Coding, HIM, and clinical teams in New York, you will ensure patient acuity is accurately reflected and support quality outcomes. The role demands strong clinical knowledge and excellent communication with providers.

Qualifications

• Current RN, PA, or NP license in NYS.
• Minimum 3 years of acute care clinical experience.
• Ability to work independently in a deadline-driven environment.

Responsibilities

• Conduct concurrent reviews of inpatient records to identify opportunities for improved documentation.
• Analyze indicators to find undocumented diagnoses or conditions.
• Determine principal and secondary diagnoses to reflect patient acuity.
• Initiate and follow up on physician queries for complete documentation.
• Build relationships with physicians to facilitate documentation improvement.
• Educate physicians on documentation best practices, in groups and 1:1.
• Document findings within CDI workflow tools.
• Collaborate with Coding, HIM, and other departments to align on documentation and level of care.
• Use leadership feedback to prioritize areas for performance improvement.
• Manage daily responsibilities in a fast-paced environment.

Skills

Strong communication

Critical thinking

Time management

Education

RN/PA/NP license in NYS

Tools

CDI workflow tools

Job description

Catholic Health Services seeks a Clinical Documentation Integrity Specialist to perform concurrent reviews of inpatient records, identify missing diagnoses, and facilitate physician queries for accurate documentation.

Collaborating with Coding, HIM, and clinical teams in New York, you will ensure patient acuity is accurately reflected and support quality outcomes. The role demands strong clinical knowledge and excellent communication with providers.