We are seeking an experienced Clinical Documentation Improvement Specialist (CDIS) for a full-time hybrid opportunity in White Plains, NY. This position is ideal for an experienced RN or PA with a strong adult acute-care background and knowledge of clinical documentation, coding, and quality measures.
Position: Clinical Documentation Improvement Specialist (CDIS)
Location: 158 Maple Ave (Winslow Hall), White Plains, NY
Work Setting: Hybrid
Schedule: Monday–Friday, 8:00 AM–4:00 PM
Hours: 75 hours per pay period
Employment Type: Full-Time
Salary: $96K–$120K per year
Job Summary
The Clinical Documentation Improvement Specialist facilitates accurate documentation for severity of illness and quality in the medical record. This position involves extensive medical record review and collaboration with physicians, Health Information Management professionals, nursing staff, coders, case managers, and other members of the care team.
Key Responsibilities
- Review medical records for completeness and accuracy related to severity of illness and quality.
- Perform accurate and timely initial and concurrent record reviews.
- Identify opportunities for clinical documentation improvement.
- Facilitate appropriate documentation to support accurate diagnosis coding and level of service.
- Formulate clinically credible documentation clarification queries.
- Support accurate documentation of principal diagnoses and comorbidities.
- Request documentation clarification related to severity of illness, risk of mortality, risk adjustment, and quality measures.
- Collaborate with physicians, nurse practitioners, case managers, coders, and other clinical staff.
- Follow up on documentation queries and ensure timely resolution.
- Collaborate with HIM coding staff to resolve discrepancies and support appropriate DRG assignment.
- Conduct post-discharge reviews and query reconciliation.
- Participate in CDI team meetings and staff education.
- Perform other related duties as assigned.
Required Qualifications
- BSN required OR Bachelor's degree (BS).
- 5 years of adult acute-care experience in Med/Surg, Critical Care, Emergency Room, or PACU.
- Minimum 70% score on the Clinical Competency Assessment (CCA).
- Strong organizational, analytical, writing, and interpersonal skills.
- Excellent critical-thinking, problem-solving, and deductive-reasoning abilities.
- Knowledge of pathophysiology, anatomy & physiology, pharmacology, and disease processes.
- Ability to correlate abnormal laboratory results with disease processes.
- Knowledge of official coding guidelines and documentation requirements related to the Inpatient Prospective Payment System.
- Knowledge of regulatory requirements, coding guidelines, and quality measures.
- Understanding of Medicare Part A and Part B guidelines and their impact on DRG assignments.
- Basic computer skills and familiarity with Windows-based software.
- RN candidates: New York State RN License required upon hire.
- PA candidates: New York State PA License required upon hire.
Pay: $96,000.00 - $120,000.00 per year
Benefits:
- 401(k) matching
- Dental insurance
- Disability insurance
- Health insurance
- Referral program
Education:
Experience:
- Acute care: 5 years (Required)
- Clinical documentation improvement: 5 years (Required)
License/Certification:
- ACTIVE NY REGISTERED NURSE (Required)
Work Location: Hybrid remote in White Plains, NY 10601
