Documentation Specialist

Confidential; New York (NY); On-site; USD 110,000 - 160,000; Full time

Job summary

Confidential is seeking a full-time, onsite Clinical Documentation Integrity (CDI) Specialist in the New York area. The role requires a clinician with extensive CDI experience and a strong clinical background to improve documentation quality, coding accuracy, and organizational performance.

You will review inpatient records, educate staff, and lead CDI meetings while collaborating with coding and quality teams. Epic or MEDITECH experience is strongly preferred.

Qualifications

• MBBS with ECFMG Certification.
• 5 years of inpatient CDI experience.
• 3 years of clinical experience in acute care.
• Expert knowledge of ICD-10-CM/PCS guidelines and documentation.
• Experience with DRG software and EHRs such as Epic or MEDITECH.
• Strong communication and relationship-building skills.

Responsibilities

• Review and audit inpatient records for accurate, complete CDI.
• Collaborate with providers and coding teams to support ICD-10-CM/PCS and DRG assignments.
• Educate physicians and staff on CDI best practices and ICD-10 guidelines.
• Develop compliant provider queries following AHIMA standards.
• Write clinical appeal letters and assist with denial management.
• Analyze CDI metrics and present findings to leadership.
• Collaborate across departments to enhance documentation and reporting.
• Assist with EMR documentation optimization in Epic or MEDITECH.
• Lead CDI meetings, sessions, and provider training.

Skills

CDI experience

Inpatient CDI

Communication

Education

MBBS with ECFMG Certification

Tools

Epic

MEDITECH

Job description

Seeking a full time ONSITE Clinical Documentation Integrity (CDI) Specialist

75 hours biweekly

Located near Queens, NY

Our healthcare client is seeking an experienced Clinical Documentation Integrity (CDI) to join its team. This role is ideal for a clinician with a strong clinical background and extensive CDI experience who is passionate about improving documentation quality, coding accuracy, and organizational performance.

Responsibilities

• Review and audit inpatient medical records to ensure accurate, complete, and compliant clinical documentation.
• Partner with providers and coding teams to improve documentation supporting accurate ICD-10-CM/PCS, APR-DRG, and MS-DRG assignment.
• Educate physicians and clinical staff on CDI best practices and ICD-10 coding guidelines.
• Develop compliant provider queries following AHIMA standards.
• Write clinical appeal letters and support denial management initiatives.
• Analyze CDI metrics, identify improvement opportunities, and present findings to hospital leadership.
• Collaborate with coding, quality, compliance, clinical applications, and interdisciplinary teams to enhance documentation and reporting.
• Assist with EMR documentation optimization in systems such as Epic or MEDITECH.
• Lead CDI meetings, educational sessions, and provider training.

Required Qualifications

• MBBS with ECFMG Certification
• 5 years of inpatient Clinical Documentation Integrity (CDI) experience.
• 3 years of clinical experience managing patients in an acute care setting.
• Expert knowledge of ICD-10-CM/PCS coding guidelines, clinical documentation, disease processes, and treatment protocols.
• Experience with DRG grouper software and electronic health records such as Epic or MEDITECH.
• Excellent communication, presentation, and relationship-building skills.

Candidates must possess at least one of the following:

• ACDIS Certified Clinical Documentation Specialist (CCDS)
• AHIMA Certified Coding Specialist (CCS)

If you're a clinically experienced CDI professional who enjoys collaborating with physicians, improving documentation quality, and driving organizational excellence, we'd love to hear from you.