Clinical Documentation Improvement Specialist

Westchester Medical Center Health Network; Town of Mount Pleasant (NY); On-site; USD 85,000 - 110,000; Full time

Job summary

Westchester Medical Center Health Network is seeking a Clinical Documentation Improvement Specialist to ensure documentation reflects care levels, severity of illness, and appropriate reimbursement. You will interact with physicians and care teams to clarify documentation and improve chart quality.

The role requires 3+ years in healthcare, CDI credentials preferred, and a Bachelor’s in a health-related field. Proficiency with Cerner Millennium and 3M CDI software is expected.

Qualifications

• Minimum of three years of healthcare experience with strong medical/surgical background.
• Experience with Coding/DRG, billing, auditing and reimbursement preferred.
• Clinician preferred with a CDIP/CCDS/CCS credential.

Responsibilities

• Review and analyze patient records to ensure accurate documentation of diagnoses and procedures.
• Notify attending physicians and staff of documentation needing clarification.
• Conduct follow-up reviews to address clarifications and document results.
• Document chart findings in the CDI database daily.
• Translate clinical phrases into coded form and verify accuracy.
• Stay current with federal and state regulatory changes for PPS (prospective payment).
• Educate care teams on chart documentation improvements.
• Serve as resource on DRG, SOI/ROM, ICD-9/10 and PCS information.
• Assist with discharge review to determine coding status.
• Complete retrospective reviews for unanswered queries.
• Suggest strategies to improve record-keeping processes.
• Ensure clinical documents comply with laws and secure storage.
• Review coding quality by reconciling MS-DRG/APR-DRG assignments.

Skills

Clinical documentation

Communication

HIM coding knowledge

Regulatory knowledge

Detail oriented

Education

Bachelor's degree in a healthcare field

Tools

Cerner Millennium EMR

3M CDI Software

Job description

Westchester Medical Center Health Network is seeking a Clinical Documentation Improvement Specialist to ensure documentation reflects care levels, severity of illness, and appropriate reimbursement. You will interact with physicians and care teams to clarify documentation and improve chart quality.

The role requires 3+ years in healthcare, CDI credentials preferred, and a Bachelor’s in a health-related field. Proficiency with Cerner Millennium and 3M CDI software is expected.