Clinical Documentation Improvement Specialist

Job Summary:

The Clinical Documentation Improvement (CDI) Specialist primary responsibility is to ensure the inpatient medical record accurately supports severity of illness and risk of mortality, as well as reflects the extent of care being provided and the resources being utilized for patients within the University Hospital system, utilizing comprehensive and broad proficiency in complex clinical and medical concepts. This is achieved by both thorough comprehensive concurrent and retrospective medical record review for accuracy, specificity, and validation of clinical diagnoses through application of clinical, documentation, and ICD-10 coding conventions, as well as Centers for Medicare and Medicaid Services (CMS) rules and regulations.

When inconsistencies, incomplete documentation, or opportunity for medical record clarification or optimization are identified, the CDI Specialist will collaborate with the medical team to clarify necessary items through a dedicated and compliant written or verbal query process. The CDI Specialist is also responsible for collaboration with the inpatient coding team to ensure the assigned final code set is reconciled pre-bill, when necessary, to resolve necessary discrepancies, as well as provider education related to documentation concepts, both written and verbal, achieved through both on-site and virtual education platforms, including in-person rounds with the interdisciplinary care team and attend various departmental and committee meetings.

Minimum Qualifications:

NYS Licensed/Registered (or eligible) RN, Bachelors Degree in Nursing (or healthcare related field) and a minimum of three years post RN licensure acute care nursing experience, or Associates Degree in Nursing and five years post RN licensure acute care nursing experience required. Must possess comprehensive and broad knowledge of complex clinical and medical concepts and demonstrate overall proficiency in clinical conceptual understanding for purposes of clinical validation.

Strong communication skills, both written and verbal, as well as interpersonal skills required for interface and collaboration with leadership, colleagues, providers, Physician Advisors, regulatory agencies, and other health care related entities required. Strong organizational skills with ability to manage assignments and responsibilities in hybrid work setting mostly independent, communicating need for additional support or guidance when necessary. Proficiency in technology use, including PC, Windows, Microsoft applications, Zoom/WebEx platforms, etc.

Preferred Qualifications:

Minimum 3 years recent inpatient nursing experience in Med/Surg, Stepdown, or Critical Care setting, preferably in an academic medical center setting highly desirable. Inpatient CDI or coding experience, preferably in an academic medical center setting highly desirable. Knowledge of community, state, and federal laws and regulations, including those of CMS preferred.

Work Days:

Monday

• Friday, 8:00 am

• 4:30 pm

Message to Applicants:

This position is primarily remote with some onsite duties.

Recruitment Office: Human Resources

Executive Order:

Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor's Office of Employee Relations at (518) 474-6988 or via email at info@goer.ny.gov.