Facility CDI Specialist

BHS; New York (NY); Remote; USD 65,000 - 90,000; Full time

Job summary

Baptist Health is seeking a Clinical Documentation Specialist for a remote role requiring residence in Kentucky or Indiana. The specialist evaluates physician documentation to ensure accurate severity of illness and supports coding accuracy by guiding physicians and care teams on documentation best practices.

Applicants should have an active Kentucky license or eligibility, with a nursing degree and relevant clinical experience.

Qualifications

• Active Kentucky nursing license or eligible
• Bachelor’s degree preferred with 3 years acute health care nursing experience (including 1 year in clinical documentation) OR Associate’s degree in Nursing with 5 years acute health care nursing
• ACDIS CCDS or CDIP strongly encouraged
• Knowledge of medical record organization
• Knowledge of medical terminology
• Ability to complete assignments in a timely manner despite workflow fluctuations
• Strong interpersonal, communication and listening skills
• Knowledge of email, Word, Excel, data entry and data retrieval systems, Encoder and internet

Responsibilities

• Evaluate physician documentation to ensure accurate severity of illness portrayal in the medical record for precise coding and increased coding accuracy
• Provide guidance to physicians, nursing and ancillary staff on clinical documentation best practices

Skills

Interpersonal skills

Communication

Medical terminology

Medical record organization

Data entry & Excel

Education

Bachelor’s degree preferred

Associate’s degree in Nursing

Tools

Word

Excel

Job description

Baptist Health is looking for a Clinical Documentation Specialist to join our team! This is a remote work position that requires residence in either KY or IN.

The Clinical Documentation Specialist is responsible for the evaluation of physician documentation utilizing their clinical expertise to ensure the patients’ severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy. They provide guidance to the physicians, nursing and ancillary staff on clinical documentation best practices. They must be self-motivated and be adaptive to change.

Requirements

• Register Nurse with active Kentucky license
• Bachelor’s degree preferred and 3 years acute health care nursing (including 1 year experience in clinical documentation), OR Associate’s degree in Nursing with 5 years acute health care nursing.
• ACDIS Credential (CCDS) or Certified Documentation Improvement Professions (CDIP) strongly encouraged
• Knowledge of medical record organization
• Knowledge of medical terminology
• Ability to complete assignments in a timely manner despite fluctuations in workflow
• Strong interpersonal, communication and listening skills is required
• Knowledge of e-mail, Word, Excel, data entry and data retrieval systems, Encoder and internet

Baptist Health is an Equal Employment Opportunity employer.