Clinical Documentation Improvement (CDI) Specialist

Santa Barbara Cottage Hospital; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider seeks a CDI Specialist responsible for enhancing the quality of clinical documentation. The role entails developing processes, collaborating with clinical staff, and ensuring compliance with standards. Ideal candidates have a strong background in nursing or health information management with a minimum of 5 years' experience.

Qualifications

• Minimum of 5 years of experience in clinical documentation improvement.
• Strong understanding of medical terminology, coding standards, and regulatory requirements.
• Ability to work independently and establish effective processes.

Responsibilities

• Develop and implement CDI processes and protocols tailored to patients.
• Conduct thorough reviews of clinical documentation to ensure accuracy.
• Collaborate with healthcare providers to clarify documentation.

Skills

Communication

Interpersonal skills

Document management

Process establishment

Education

Bachelor's degree in Nursing

Health Information Management

Certified Clinical Documentation Specialist (CCDS)

Tools

CDI software

EHR systems

Job description

About Us

We are Emerus, the leader in small-format hospitals. We partner with respected and like-minded health systems who share our mission: To provide the care patients need, in the neighborhoods they live, by teams they trust. Our growing number of amazing partners includes Allegheny Health Network, Ascension, Baptist Health System, Baylor Scott & White Health, ChristianaCare, Dignity Health St. Rose Dominican, The Hospitals of Providence, INTEGRIS Health, MultiCare and WellSpan. Our innovative hospitals are fully accredited and provide highly individualized care. Emerus' commitment to patient care extends far beyond the confines of societal norms. We believe that every individual who walks through our doors deserves compassionate, comprehensive care, regardless of their background, identity, or circumstances. We are committed to fostering a work environment focused on teamwork that celebrates diversity, promotes equity and ensures equal access to information, development and opportunity for all of our Healthcare Pros.

Position Overview

The CDI Specialist will be responsible for improving the overall quality and completeness of clinical documentation. This role requires significant experience in CDI, as the specialist will be the sole member of the department. The ideal candidate will be adept at creating and establishing processes, working independently, and collaborating with healthcare providers to ensure accurate and comprehensive patient records.

Essential Job Functions

• Develop and implement CDI processes and protocols tailored to our med/tele and ED patient populations.
• Conduct thorough reviews of clinical documentation to ensure accuracy, completeness, and compliance with regulatory standards.
• Collaborate with physicians, nurses, and other healthcare providers to clarify documentation and ensure it accurately reflects patient care.
• Educate and train clinical staff on best practices for documentation improvement.
• Utilize CDI software and tools to track and analyze documentation trends and outcomes.
• Prepare and present regular reports on CDI activities and outcomes to senior management.
• Stay current with industry standards, regulatory requirements, and best practices in clinical documentation.

Other Job Functions

• Attend staff meetings or other company sponsored or mandated meetings as required
• Travel to all facility locations as required
• Perform additional duties as assigned
• Ability to work off-hours when required

Basic Qualifications

• Bachelor's degree in Nursing, Health Information Management, or a related field.
• Certified Clinical Documentation Specialist (CCDS) or similar certification preferred.
• Minimum of 5 years of experience in clinical documentation improvement.
• Strong understanding of medical terminology, coding standards, and regulatory requirements.
• Excellent communication and interpersonal skills.
• Ability to work independently and establish effective processes.
• Proficiency with CDI software and electronic health records (EHR) systems.