CDI Specialist - Elevate Patient Care with Accurate Docs

Catholic Health; Melville (NY); On-site; USD 105,000 - 150,000; Full time

Job summary

Catholic Health in Melville, NY is seeking a Clinical Documentation Integrity (CDI) Specialist to conduct concurrent reviews of inpatient records to ensure accurate, complete documentation and support appropriate care, coding, and quality outcomes. The role requires 3+ years of acute care experience, an NYS license, strong clinical knowledge, and excellent communication.

You will query physicians, educate teams, and collaborate with Coding, HIM, and other departments to improve documentation

Qualifications

• Current NYS RN, PA, or NP license.
• Minimum of 3 years of clinical experience in an acute care setting.
• Strong clinical knowledge, including pathology and physiology.
• Excellent written and verbal communication skills.
• Ability to work independently and manage time effectively in a deadline-driven environment.

Responsibilities

• Conduct initial and follow-up concurrent reviews of inpatient medical records to identify opportunities for improved documentation.
• Analyze clinical indicators to identify diagnoses or conditions not yet documented in the record.
• Determine and validate the appropriate principal and secondary diagnoses to accurately reflect patient acuity.
• Initiate and follow up on physician queries (written and verbal) to obtain complete and accurate documentation.
• Build and maintain strong working relationships with physicians to facilitate effective communication and documentation improvement.
• Provide education to physicians on documentation best practices, both in group settings and one-on-one.
• Document review findings and key information within workflow and tracking tools.
• Collaborate with Coding, HIM, and other departments to ensure alignment on documentation and level of care.
• Utilize data and feedback from leadership to prioritize focus areas and improve performance.
• Manage daily responsibilities effectively, maintaining flexibility in a fast-paced environment.

Skills

Clinical documentation knowledge

Communication skills

Critical thinking

Independent work

Interpersonal skills

Education

NYS RN/PA/NP license

3+ years acute care experience

Tools

CDI workflow tools

Job description

Catholic Health in Melville, NY is seeking a Clinical Documentation Integrity (CDI) Specialist to conduct concurrent reviews of inpatient records to ensure accurate, complete documentation and support appropriate care, coding, and quality outcomes. The role requires 3+ years of acute care experience, an NYS license, strong clinical knowledge, and excellent communication.

You will query physicians, educate teams, and collaborate with Coding, HIM, and other departments to improve documentation