Clinical Documentation Improvement Specialist II

Mount Sinai Morningside; New York (NY); On-site; USD 80,000 - 109,000; Full time

Job summary

Mount Sinai Morningside is seeking a Clinical Documentation Quality Improvement Specialist II to enhance the completeness and accuracy of medical record documentation. You will work with physicians, nursing staff, and coding teams to ensure documentation reflects the true level of service rendered, supporting accurate DRG classification and reimbursement.

The role requires 2–4 years of CDI experience, strong analytical and communication skills, and knowledge of ICD-10-CM/PCS and CPT coding.

Qualifications

• 2 years of CCS, CDIP or CCDS or equivalent
• Good written, oral and interpersonal skills
• Excellent problem solving and analytical skills
• Strong organization skills
• Attention to details
• Strong computer skills
• Demonstrated knowledge of ICD-10 CM/PCS codes, DRG and CPT coding

Responsibilities

• Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records
• Facilitates accurate clinical documentation to ensure appropriate DRG classification is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer
• Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation.
• Ability to write queries that are concise and easily understood by the queried provider, in order to garner additional necessary documentation in the inpatient medical record
• Timely reconciliation of all cases, to include accurate recording of DRG or SOI impact based on physician query, as well as physician response to all queries
• Identify query opportunities, diagnoses not supported by clinical indicators, and function on par with other CDI team members
• Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team
• Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations
• Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisor
• Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI.
• Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data and clinical validation.
• Performs other related duties.

Skills

CDQI experience

Analytical skills

Attention to detail

Problem solving

Organizational skills

Written and interpersonal skills

ICD-10 CM/PCS knowledge

CPT coding knowledge

Job description

Description

Job Description

The Clinical Documentation Quality Improvement Specialist II is responsible for improving the overall quality and completeness of clinical documentation; facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that documentation reflects complete and accurate level of service rendered to patients. Performance Requirement for CDQI Specialist II 1. Experienced CDQI with minimum 2-4 years recent experience in CDI role 2. To meet quality and quantity expectations within 6 months of employment 3. Quality review: ≥ 93%; 4. Quantity: 10-14 Initial Chart reviews, >5 agree queries per work days. 5. Attains Clinical Documentation Specialist certification through ACDIS or AHIMA 6. The CDI specialist II also assists leadership in utilizing expertise in CDI and data analysis in evaluating CDI accuracy, standardizing review findings and reporting out results 7. Works effectively and efficiently, able to work on several things at once while maintaining expected productivity outcomes. Meets established productivity goals without sacrificing quality.

Responsibilities

Roles & Responsibilities:

• Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through concurrent auditing and evaluation of the medical records
• Facilitates accurate clinical documentation to ensure appropriate DRG classification is received for the level of service rendered to all patients with a Diagnosis-Related Group (DRG) payer
• Analyzes clinical status of patient, current treatment plan and past medical history to identify potential gaps in clinical documentation.
• Ability to write queries that are concise and easily understood by the queried provider, in order to garner additional necessary documentation in the inpatient medical record
• Timely reconciliation of all cases, to include accurate recording of DRG or SOI impact based on physician query, as well as physician response to all queries
• Identify query opportunities, diagnoses not supported by clinical indicators, and function on par with other CDI team members
• Demonstrate an understanding of complications, comorbidities, SOI, ROM, case mix, and the impact of procedures on the billed record, as well as the ability to impart this knowledge to providers and other members of the healthcare team
• Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations
• Collaborate with HIM/coding professionals to review individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisor
• Communicate with appropriate healthcare team members to promote accurate and complete documentation of diagnoses and/or procedures in the health record that have direct bearing on SOI.
• Act as a consultant to coding professionals when additional information or documentation is needed to assign coded data and clinical validation.
• Performs other related duties.
  
  

Qualifications

Requirements

• 2 years of CCS, CDIP or CCDS or equivalent
• Good written, oral and interpersonal skills
• Excellent problem solving and analytical skills
• Strong organization skills
• Attention to details
• Strong computer skills
• Demonstrated knowledge of ICD-10 CM/PCS codes, DRG and CPT coding
  
  

Employer Description

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history.

About The Mount Sinai Health System

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.

Compensation

The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $79720 - $108709 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.