Clinical Documentation Integrity Specialist (CDI)

Summa Health

Cleveland (OH)

On-site

USD 52,000 - 77,000

Full time

4 hours ago

Be an early applicant

Application generator

Turn this role into an interview — a resume and cover letter built around what this employer wants.

Get past ATS filters

Benefits offered by this job

Basic Life and AD&D

Supplementary Life Insurance

Dependent Life Insurance

Short-Term Disability

Long-Term Disability

Retirement Savings Plan

Flexible Spending Accounts

Employee Assistance Program

Identity Theft Protection

Education Assistance

Daily Pay

Job summary

Summa Health is seeking a Clinical Documentation Integrity Specialist to facilitate concurrent documentation, ensuring accurate inpatient coding and DRG assignments. The role requires educating physicians on documentation needs and collaborating with physician advisors to optimize reimbursement.

The position emphasizes adherence to coding guidelines, clinical process knowledge, and the ability to operate in a sometimes high-pressure environment while maintaining patient-focused service.

Qualifications

Graduate of accredited health information management or coding program or a school accepted for candidacy status from an accrediting body.
Graduate of an accredited school of professional nursing or a school accepted for candidacy status from an accrediting body.
RHIA, RHIT, CCA, CCS, CCDS, CDIP, CPCH, or CDIP certification preferred.

Responsibilities

Facilitates concurrent documentation of the medical record to achieve accurate inpatient coding and DRG assignments.
Reviews chart documentation for quality metric indicators for severity of illness, risk of mortality, and risk adjusters.
Educates physician on documentation needs through the query process.
Directly works with Physician Advisors as well as the patient’s physician to establish concise physician documentation.

Skills

Communication skills

Leadership

Organizational skills

Interpersonal skills

Coding guidelines knowledge

Clinical processes knowledge

Stress management

Population-specific competency

Education

Health information management/coding program graduate

Nursing program graduate

CDI/clinical coding certifications preferred

Job description

Clinical Documentation Integrity Specialist

Full-Time Days

Summa Health System is recognized as one of the region’s top employers by a number of third party organizations, including NorthCoast 99. Exceptional candidates gravitate to Summa because of its culture, passion for delivering excellent service to our patients and families commitment to our philosophy of servant leadership, collegial working relationships at every level of the organization and competitive pay and benefits.

Summary

Facilitates concurrent documentation of the medical record to achieve accurate inpatient coding and DRG assignments to ensure the principal diagnosis, comorbidities and principal procedure are appropriate and supported for reimbursement. Reviews chart documentation for quality metric indicators for severity of illness (SOI), risk of mortality (ROM), and risk adjusters (readmission criteria). Educates physician on documentation needs through the query process. Directly works with Physician Advisors as well as the patient’s physician to establish concise physician documentation; ensures physician awareness of documentation guidelines in relation to coding guidelines that support appropriate reimbursement. If any type of nursing judgement, nursing practice or medical judgement questions should arise, those questions/concerns will be elevated to the Chief Nurse Executive (CNE).

Formal Education Required

Graduate of accredited health information management or coding program or a school accepted for candidacy status from an accrediting body
Graduate of an accredited school of professional nursing or a school accepted for candidacy status from an accrediting body
RHIA, RHIT, CCA, CCS, CCDS, CDIP, CPCH, or CDIP certification preferred

Experience & Training Required

One (1) year medical records experience (practicum experience will be counted) if graduate of health information management or coding program
Two (2) years professional nursing experience which should include a combination of medical, specialty and/or surgical care in an acute care setting or utilization review with DRG validation experience if minimum education level is graduate of nursing school

Other Skills, Competencies And Qualifications

75% or better on a CDI Specialist Test
Excellent communication both verbally and written, leadership, organization and interpersonal skills.
Ability to work within a team environment yet self-motivated, facilitate strategic development, knowledge of accrediting, licensing and compliance requirements
Extensive knowledge of coding guidelines required
Extensive knowledge of clinical processes required
Ability to work in a sometimes stressful environment
Population Specific Competency: ability to effectively interact with populations of patients/customers with an understanding of their needs for self-respect and dignity.

Level Of Physical Demands

Sedentary: Exerts up to ten pounds of force occasionally and/or a negligible amount of force frequently.

Equal Opportunity Employer/Veterans/Disabled

$37.40/hr - $56.11/hr

The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.

Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other benefits.