CDI Specialist I: Elevate Clinical Documentation Quality

WellSpan Health; York (York County); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement savings plan

Paid time off (PTO)

Education assistance

Financial education and support, Daily

Expanded Paid Parental Leave

Job summary

WellSpan Health in York, PA seeks a Clinical Documentation Integrity Specialist to improve the quality and completeness of provider-based documentation in medical records. You will support physicians and HIM staff to ensure documentation accurately reflects severity of illness and services rendered, enabling appropriate coding and reimbursement.

Responsibilities include conducting initial, concurrent, and retrospective chart reviews, identifying gaps, and issuing credible clarifications.

Qualifications

• Diploma Program in Nursing or Associates/Bachelor's degree preferred.
• 5 years recent hospital experience; CDI experience required.
• CDI experience as concurrent or retrospective documentation specialist in inpatient acute care facility.
• Clinical Documentation Integrity experience preferred.

Responsibilities

• Reviews hospitalized patients' medical records to identify principal diagnosis and assign a DRG.
• Performs initial, concurrent, and retrospective reviews to ensure DRG accuracy.
• Completes chart reviews using an organized approach across chart components.
• Follows query through to closure with ongoing follow up activities.
• Collaborates with coding staff to ensure documentation supports accurate coding.
• Provides CDI education to providers and participates in meetings.
• Maintains integrity and compliance in chart reviews and queries.

Skills

Organized

Analytical thinking

Critical thinking

Problem solving

PowerPoint

Excel

Microsoft Office

Education

Diploma Program in Nursing

Associates Degree

Bachelor's Degree

Tools

APR-DRG encoder

Job description

WellSpan Health in York, PA seeks a Clinical Documentation Integrity Specialist to improve the quality and completeness of provider-based documentation in medical records. You will support physicians and HIM staff to ensure documentation accurately reflects severity of illness and services rendered, enabling appropriate coding and reimbursement.

Responsibilities include conducting initial, concurrent, and retrospective chart reviews, identifying gaps, and issuing credible clarifications.