Clinical Documentation Integrity Specialist II

AdventHealth

Shawnee (KS)

On-site

USD 68,000 - 126,000

Full time

Just now

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Benefits offered by this job

Medical, Dental, Vision Insurance

Life Insurance

Disability Insurance

Paid Time Off from Day One

403-B Retirement Plan

4 Weeks 100% Paid Parental Leave

Career Development

Whole Person Well-being Resources

Mental Health Resources and Support

Pet Benefits

Job summary

AdventHealth is seeking a Clinical Document Specialist II to support CDI initiatives remotely from Kansas. The role focuses on accurate documentation to reflect severity, ROM, and quality metrics in Obstetrics and NICU care, partnering with physicians and care teams.

Responsibilities include reviewing records, issuing clarifications, maintaining CDI data, and guiding staff through regulatory requirements. A KS license and CCDS certification are required or preferred.

Qualifications

RN license active in KS.
CCDS certification required.
5+ years CDI experience in obstetric/NICU settings.
BSN preferred.”

Responsibilities

Facilitates CDI activities to ensure accurate patient acuity, ROM, and quality outcomes.
Reviews concurrent records for completeness, accuracy, and compliance.
Develops clinically supported documentation clarifications for physicians and staff.
Maintains CDI data in designated systems for reporting and metrics.
Collaborates with physicians, HIM staff, and care teams to improve documentation quality.

Skills

CDI experience

RN nursing experience

Regulatory knowledge

Coding concepts

Interdisciplinary collaboration

Education

RN or AA degree

CCDS certification

BSN preferred

JATA training

Job description

Our Promise To You

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Our Promise To You

All the benefits and perks you need for you and your family:

Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
Paid Time Off from Day One
403-B Retirement Plan
4 Weeks 100% Paid Parental Leave
Career Development
Whole Person Well-being Resources
Mental Health Resources and Support
Pet Benefits

Schedule

Full time

Shift

Day (United States of America)

Address

9100 W 74TH ST

City

SHAWNEE MISSION

State

Kansas

Postal Code

66204

Job Description

Clinical Document Specialist II – Full-Time

Location:

Remote- role is fully Remote-**must be licensed in KS**

Schedule:

Full-Time | Day Shift

Required: Kansas Nursing License or current Multi-State Nursing License

Job Summary

Responsible for facilitating and obtaining accurate, complete, and compliant physician documentation to support the severity of illness, risk of mortality, quality outcomes, and complexity of Obstetrics and NICU patient care. Educates physicians, advanced practice providers, nursing staff, care management, and other healthcare professionals regarding documentation standards, regulatory requirements, and clinical documentation improvement (CDI) practices. Ensures adherence to organizational policies, regulatory guidelines, departmental goals, and performance standards while promoting documentation integrity and compliance. Contributes to the efficiency and effectiveness of clinical documentation processes through collaboration, critical thinking, and continuous improvement efforts.

Essential Functions

Facilitates clinical documentation improvement activities to ensure accurate representation of patient acuity, severity of illness, risk of mortality, and quality outcomes.
Reviews concurrent medical records for completeness, accuracy, compliance, and documentation opportunities.
Identifies opportunities for documentation improvement through analysis of clinical indicators, medical necessity, and patient care documentation.
Develops and communicates clinically supported documentation clarifications to physicians, advanced practice providers, and other members of the healthcare team.
Initiates and formulates CDI severity worksheets and documentation queries that support compliant documentation practices.
Reviews and reconciles documentation related to severity of illness (SOI), risk of mortality (ROM), patient safety indicators (PSI), hospital-acquired conditions (HAC), hierarchical condition categories (HCC), and other quality measures.
Accurately enters and maintains CDI data within designated software systems, supporting reporting and performance metrics.
Collaborates with physicians, nursing staff, HIM professionals, coders, and other healthcare team members to improve documentation quality and accuracy.
Works with Health Information Management staff to resolve DRG assignment discrepancies and coding-related documentation issues.
Conducts timely follow-up reviews on concurrent cases and prioritizes cases requiring clarification resolution.
Educates physicians, advanced practice providers, nursing staff, and other healthcare professionals regarding documentation requirements, regulatory guidelines, and best practices.
Maintains physician engagement and supports timely responses to documentation clarification requests.
Participates in departmental meetings, educational initiatives, performance improvement activities, and process improvement efforts.
Assists with orientation, training, mentoring, and precepting of new team members.
Completes annual educational projects and presentations for the CDI team.
Maintains documentation integrity and compliance with organizational, regulatory, and accreditation requirements.
Performs other duties as assigned.

Knowledge, Skills, And Abilities

Excellent verbal and written communication skills with the ability to develop and maintain effective professional relationships.
Demonstrated ability to communicate effectively with physicians, advanced practice providers, and interdisciplinary healthcare teams.
Strong organizational, prioritization, and time management skills.
Ability to manage multiple responsibilities and competing priorities in a fast-paced healthcare environment.
Proficiency in computer applications, electronic health record systems, CDI software, and related technologies.
Ability to work effectively with multiple software applications simultaneously.
Strong critical thinking, clinical reasoning, problem-solving, and decision-making skills.
Ability to analyze clinical documentation and identify opportunities for improvement.
Knowledge of pathophysiology, disease processes, clinical treatment modalities, and patient care practices.
Knowledge of clinical documentation improvement principles and documentation requirements.
Knowledge of coding concepts, DRG methodology, reimbursement systems, and healthcare quality measures.
Knowledge of regulatory, compliance, accreditation, and quality reporting requirements.
Ability to organize, interpret, and present information clearly and concisely.
Demonstrated ability to learn, develop, and refine clinical documentation improvement skills.
Dependable, self-motivated, professional, and collaborative.
Ability to work independently while maintaining strong teamwork and customer service standards.

Education

RN/Associate's Degree required.
BSN Preferred

Field of Study

Nursing or a health-related field.

Work Experience

5 years of Clinical Documentation Integrity (CDI) experience involving Obstetric and/or Neonatal Intensive Care Unit (NICU) patient populations, including review of Obstetric and NICU cases.
Acute care nursing experience in Obstetrics, Labor & Delivery, Mother-Baby, Women's Services, NICU, or related specialties strongly preferred.
Five years of Clinical Documentation Improvement (CDI) experience required.

Required Education