Clinical Documentation Integrity Specialist (CDI Specialist)
- Location: Miramar, Florida
- Position Type: Full-Time Employment
- Number of Openings: 8
- Start Date: ASAP / Based on candidate availability
- On-site Requirements: Hybrid Eligible (anywhere in Florida but must reside in Florida and can work almost entirely remote)
- Relocation: Potentially available for highly qualified candidates
Position Summary
Hospital system is seeking a Clinical Documentation Integrity Specialist (CDI Specialist) to support ongoing documentation integrity initiatives across the health system. This role is responsible for improving the overall quality, completeness, and accuracy of provider documentation to ensure patient acuity, severity of illness, risk of mortality, reimbursement integrity, and quality outcomes are appropriately reflected within the medical record.
The CDI Specialist will work collaboratively with physicians, nursing staff, coding professionals, quality teams, and clinical leadership to facilitate compliant provider documentation clarification practices and support accurate DRG assignment and clinical documentation standards.
This individual will serve as a key resource in physician education, concurrent medical record review, documentation compliance, and CDI reporting initiatives within a highly collaborative healthcare environment.
Key Responsibilities / Job Duties
- Review inpatient electronic medical records concurrently to identify documentation improvement opportunities
- Construct compliant provider documentation clarifications/queries to improve documentation accuracy
- Ensure severity of illness (SOI), risk of mortality (ROM), and patient acuity are accurately reflected in documentation
- Assign and update working DRGs, diagnoses, and procedures during ongoing record review
- Collaborate closely with physicians, nursing staff, coding teams, quality management, and HIM leadership
- Provide one-on-one and group education to physicians, APPs, nursing staff, and allied health professionals regarding documentation integrity and compliance
- Partner with CDI Auditors and HIM leadership on ongoing staff education initiatives
- Conduct follow-up reviews to ensure provider clarification opportunities have been addressed appropriately
- Collaborate with coding teams regarding clinical presentation, coding guidelines, and documentation clarification opportunities
- Generate CDI reports to monitor:
- Provider clarification response rates
- Case Mix Index (CMI)
- Reimbursement impact
- Documentation quality trends
- Participate in quality improvement initiatives related to PSIs, HACs, BPCI, and DRG optimization efforts (Remote Nursing Jobs)
Position Qualifications
- Graduate of an accredited Nursing or Health Information Management program
- One of the following credentials required:
- Registered Nurse (RN)
- RHIT
- RHIA
- CCS
- Active Florida RN license or Compact RN license if applicable
- Minimum of:
- Two (2) years of clinical nursing experience OR
- Two (2) years of inpatient coding experience
- Strong understanding of:
- Clinical documentation improvement (CDI)
- DRG assignment methodologies
- ICD-10 coding principles
- Medical terminology
- Inpatient clinical workflows
- Experience working with EMRs and computerized encoder systems
- Proficiency with Microsoft Office applications
- Strong communication and physician collaboration skills
- Ability to work independently in a fast-paced healthcare environment (Remote Nursing Jobs)
#INDFLEX
Pay: Up to $95,000.00 per year
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Vision insurance
Work Location: Remote
