Clinical Documentation Integrity (CDI) Specialist

Cayuga Medical Center; Town of Ithaca (NY); On-site; USD 75,000 - 110,000; Full time

Job summary

Cayuga Health System seeks a Clinical Documentation Integrity (CDI) Specialist to partner with physicians, nursing, HIM, coding and billing to improve documentation quality and DRG accuracy. You will query providers to clarify gaps, ensure ICD-10 coding alignment with CMS rules, and support hospital reimbursement while maintaining patient confidentiality.

This full-time role reports to the Team Lead UR/CDI and requires 2-3 years CDI experience, nursing background preferred, with a strong grasp

Qualifications

• Requires nursing background or equivalent CDI experience.
• Experience with CMS regulations and payer requirements.
• Strong communication and problem-solving skills.

Responsibilities

• Promote Cayuga Health System mission and values.
• Assess documentation to reflect level of care and severity.
• Identify gaps in physician documentation and issue queries.
• Refine principal diagnosis to support DRG assignments.
• Develop DRG concepts after physician/HIM review.
• Apply HIM coding standards to ongoing documentation evaluation.
• Participate in denial management for DRG adjustments.
• Collaborate with teams; remain flexible and available to staff.
• Serve on hospital committees and share knowledge.
• Maintain up-to-date knowledge of coding standards and guidelines.
• Review regulatory reports to maximize reimbursement and reduce risk.
• Seek learning experiences to improve performance.

Skills

Clinical Documentation Integrity

ICD-10 Coding Knowledge

Team Collaboration

Regulatory Compliance

Education

Bachelor of Science in Nursing

Associate Degree with 3-5 years CDI experience

CCS/CCS-P/CPC Certification preferred

Job description

Job Description

Job Title: Clinical Documentation Integrity (CDI) Specialist

Department: Clinical Resource Management

Reports To: Team Lead UR/CDI, System Director of Utilization and Care Management

Job Summary

The CDI specialist proactively collaborates with physicians, nursing, caregivers, Health Information Management, coding and billing to improve the quality and completeness of documentation of care provided. The CDI specialist will query providers as indicated to clarify gaps in documentation and support and record appropriate ICD-10 diagnosis codes in alignment with CMS and other health system regulatory agencies. Ensures accuracy and quality among medical coders, providers, nurses, billing teams, and other healthcare professional as indicated to optimize revenue for the health system.

Job Responsibilities include:

• Promote the mission, vision, and values of Cayuga Health System.
• Reviews and recommends appropriate level of care and utilization, in collaboration with case managers and social workers, to optimize the length of stay and appropriate placement of patients under DRG payers.
• Assesses clinical documentation to ensure documentation reflects the level of service rendered and severity of illness in compliance with governmental and payer requirements for all patients.
• Identifies potential gaps in physician documentation. Sends, follows-up, tracks and reports queries and associated responses as indicated.
• Recommends possible refinement of principal diagnosis based on clinical data on admission and concurrently during the hospital stay to facilitate appropriate DRG assignment
• Develops a working DRG based on the clinical documentation and interaction with physicians and HIM staff.
• Demonstrates basic knowledge of HIM standards of coding, coding clinics and applies to on-going evaluation of medical record documentation.
• Participates in the denial management processes for both DRG adjustments and for medical necessity denials as assigned.
• Demonstrates and promotes teamwork, the ability to remain flexible and re-prioritize to cover staffing changes or gaps. Maintains high visibility within the hospital while readily accessible to staff, e.g. providers and nursing.
• Positively and effectively serves on hospital committees as assigned.
• Appropriately shares knowledge with coworkers.
• Maintains working knowledge of coding standards and guidelines.
• Reviews and analyzes regulatory reports and waivers. Identifies and shares with colleagues any actions to maximize hospital reimbursement, minimize risk, and identify opportunities for improvement.
• Seeks our new learning experiences to optimize job performance.
• Regular attends team meetings - provides advanced notice if go be missed and appropriately seeks information missed.
• Exemplify satisfactory attendance and punctuality record as set forth by CHS policies.
• Exemplify a professional image in appearance, manner and presentation.
• Maintains patient confidentiality in the provision of quality care.
• Is flexible in assuming other appropriate responsibilities not noted above.

Requirements:

Education -Bachelors in nursing preferred, or Associates Degree with 3-5 years of CDI experience. CCS, CCS-P, or CPC Certification preferred.

Experience - Minimum 2 to 3 years' experience in an acute care CDI role. Knowledge of federal, state and accreditation standards. Requires strong verbal and written communication skills, organizational, critical thinking and problem solving skills. Must be able to work in a team environment and exhibit flexibility and enthusiasm in learning new information and developing new skills quickly. Knowledge of pertinent Federal, State, and local laws, codes, and regulations.

Physical Requirements

- Ability to stand, sit or ambulate for long periods. Ability to transport self to customer base. Ability to ambulate freely around nursing units. Use of hands and fingers for keyboard and computer data entry into EMR. Ability to transport self to customer base.