Clinical Documentation Integrity Specialist

Episcopal Health Services; New York (NY); On-site; USD 73,000 - 99,000; Full time

Job summary

Episcopal Health Services (EHS) in New York is seeking an experienced CDI specialist to ensure accurate clinical documentation and coding for inpatient services. The role collaborates with providers, coders, and leadership to optimize DRG assignments and compliance.

You will educate clinicians on documentation standards, perform record audits, and drive improvements across the CDI program within a major NY health system.

Qualifications

• 5+ years inpatient CDI experience.
• 3+ years clinical experience managing patients in acute care.
• MD/DO/MBBS with relevant certifications in CDI required.
• Familiar with ICD-10-CM/PCS coding guidelines.
• Audits and provider education experience.

Responsibilities

• Educates providers on documentation best practices aligned with ICD-10-CM/PCS guidelines.
• Performs audits of medical records to ensure accurate coding.
• Collaborates with leadership, providers, quality, compliance, and coding teams.
• Writes clinical appeal letters and supports denial management.
• Develops DRG assignment support with inpatient coders.
• Designs and presents CDI program metrics to Hospital Leadership.

Skills

ICD-10-CM/PCS coding

Clinical documentation

Communication skills

Auditing

Training presentations

Education

MD

DO

MBBS/ECFMG Certified

Tools

Meditech

Epic

Job description

EHS Overview:

Episcopal Health Services Inc. (EHS) is a health system located on the Rockaway Peninsula in Queens, New York. EHS provides inpatient, outpatient, and emergency care to the diverse populations of the Rockaways, Five Towns, South Nassau, and beyond. The system offers comprehensive preventive, diagnostic, and rehabilitative services to people of all faiths.

St. John’s Episcopal Hospital is accredited by The Joint Commission’s Health Facilities Accreditation Program and is approved by the New York State Department of Health. The hospital is a recipient of the Gold-Plus Get with the Guidelines®-Stroke Quality Achievement Award and the Gold-Plus Get with the Guidelines®-Heart Failure Quality Achievement Award from the American Heart Association. Additionally, St.John's is proud to be redesignated as a Baby-Friendly® Hospital by Baby-Friendly USA – the accrediting body and national authority for the Baby-Friendly Hospital Initiative (BFHI) in the United States.

Come Grow With Us!

Type: Full-Time (75 hours biweekly)

Shift: Days

Hours: Varies

Salary: $86,000

POSITION SUMMARY:

• Possesses strong clinical foundation with respect to differential diagnoses, disease interactions, pathophysiology, and treatment protocols
• Demonstrates mastery of ICD-10-CM/PCS coding guidelines
• Serves as liaison between providers and coders, with respect to crosswalk between clinical language and coding terminologies
• Educates providers on clinical documentation best practices aligned with ICD-10-CM/PCS Official Guidelines for Coding and Reporting
• Performs audits of medical records to ensure that provider documentation is accurate and complete and that correct ICD-10-CM/PCS codes are captured
• Fosters collaborative relationships with Hospital Leadership, providers, clinical teams, quality teams, compliance teams, and coding team
• Displays excellent oral and written communication skills
• Demonstrates proficiency developing and delivering presentations for training and education
• Demonstrates proficiency with DRG grouper software and electronic health records (e.g., Meditech, Epic)ESSENTIAL

FUNCTIONS:

• Demonstrates qualities outlined in the “Customer Service Standards of Excellence” program when interacting with patients, their families and friends, and fellow employees
• Maintains compliance with internal and external policies, procedures, regulations, industry guidelines and objectives, HIPAA and safety standards
• Develops, coordinates and performs internal auditing activities, to ensure compliance with best practices for clinical documentation and coding
• Collaborates with inpatient coders to support accurate APR-DRG and MS-DRG assignment
• Writes clinical appeal letters and supports denial management process
• Generates clinically robust queries for providers and adheres to AHIMA Guidelines for Achieving a Compliant Query Practice
• Communicates with providers to obtain timely and compliant query responses
• Tracks, analyzes and trends data to identify opportunities for performance improvement
• Monitors, tracks and maintains key CDI metrics
• Educates providers on documentation best practices to ensure the most appropriate and specific ICD-10-CM/PCS codes are captured in accordance with State, Federal and other accrediting agencies
• Collaborates with interdisciplinary teams to identify opportunities and establish a unified approach for clinical documentation review, audit and education
• Collaborates with Clinical Applications department to create and implement EMR components for complete and accurate provider clinical documentation and appropriate APR-DRG and MS-DRG assignment
• Designs and presents CDI program metrics to Hospital Leadership
• Leads and/or participates in meetings pertaining to CDI

EDUCATION:

Requirement for one of the following:

MD: Medical Doctor
DO: Doctor of Osteopathy
MBBS/ECFMG Certified

CERTIFICATION:

Requirement for at least one of the following:

AHIMA Certified Documentation Improvement Practitioner (CDIP)
ACDIS Certified Clinical Documentation Specialist (CCDS)
AHIMA Certified Coding Specialist (CCS)

EXPERIENCE:

5+ years inpatient CDI experience.
3+ years clinical experience managing patients in acute care setting