Clinical Documentation Integrity (CDI) Specialist

Cayuga Health, A Member of Centralus Health; Town of Ithaca (NY); On-site; USD 85,000 - 110,000; Full time

Job summary

Cayuga Health, a member of Centralus Health, seeks a CDI Specialist to collaborate with physicians, nursing, HIM, coding and billing to improve documentation quality and support appropriate ICD-10 coding in alignment with CMS and regulatory agencies.

The CDI Specialist will query providers to clarify gaps in documentation and ensure quality and compliance, balancing patient care with cost efficiency and revenue optimization.

Qualifications

• Bachelor's degree in nursing preferred; or an Associate's degree with 3–5 years inpatient clinical experience.
• CCDS, CDIP, CCS, CCS-P, or CPC certification preferred.
• Strong verbal and written communication, organizational and problem-solving skills.

Responsibilities

• Promote Cayuga Health System's mission, vision and values.
• Assess clinical documentation to reflect level of service and severity of illness per requirements.
• Follow-up evaluation of documentation to ensure issues are recorded in the medical record.
• Identify gaps in provider documentation; manage queries and responses.
• Recommend refinement of principal diagnosis to facilitate appropriate DRG assignment.
• Participate in provider education to promote accurate, complete documentation per guidelines.
• Demonstrate knowledge of HIM coding standards and apply to ongoing documentation evaluation.
• Participate in denial management for DRG adjustments and medical necessity denials.
• Maintain knowledge of regulatory requirements for utilization practices and Medicare/Medicaid processes.
• Share knowledge with coworkers and contribute to continuous improvement.
• Review regulatory reports to identify actions to maximize reimbursement and minimize risk.
• Attend team meetings and maintain professional appearance and punctuality.
• Maintain patient confidentiality in quality care.
• Be flexible in assuming other appropriate responsibilities.

Skills

Communication

Collaboration

Problem-solving

Education

BSN preferred

Associates with 3–5 years inpatient experience

CCDS/CDIP/CCS/CCS-P/CPC certification preferred

Job description

Job Description

Job Title: CDI Specialist

Department: Clinical Resource Management

Reports To: System Manager of CDI, System Senior Director of Care Transitions

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 professionals as indicated to optimize revenue for the health system.

Cayuga Health seeks an experienced RN with experience in CDI, case management, utilization review, or other systems of managed care. The CDI Specialist's goal is to balance the quality of patient care with cost efficiency, ultimately maximizing the continuity of care a patient receives while preventing and managing denials.

Job Responsibilities Include

• Promote the mission, vision, and values of Cayuga Health System.
• 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
• Conducts follow‑up evaluation of clinical documentation to ensure issues discussed and clarified with the provider have been appropriately recorded in the patient's medical record
• Identifies potential gaps in provider 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
• Participates in the development and delivery of provider education to promote accurate, complete, and compliant clinical documentation in accordance with coding guidelines, regulatory requirements, and organizational CDI initiatives
• 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
• Maintains current knowledge of regulatory and compliance requirements, and policies and procedures for utilization practices, processes and criteria. Assure compliance with Medicare and Medicaid utilization processes.
• Appropriately shares knowledge with coworkers.
• Participates in the development of actions for improvement.
• 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
• Regular attends team meetings - provides advanced notice if going to 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 inpatient clinical experience. CCDS, CDIP, CCS, CCS-P, or CPC Certification preferred.

Experience

- Minimum 2 to 3 years' experience in an acute care 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 hospital as needed. Ability to ambulate freely around nursing units. Use of hands and fingers for keyboard and computer data entry into EMR.