Clinical Documentation Improvement Specialist (CDIS)

Brookdale Associates • White Plains, NY

443d • $90,000 - $140,000

About The Position

The Clinical Documentation Improvement Specialist (CDIS) plays a vital role in ensuring accurate and comprehensive documentation within medical records, focusing on the severity of illness and quality of care. This position involves collaboration with healthcare professionals, conducting thorough record reviews, and providing education on the Clinical Documentation Improvement Program (CDIP). The CDIS is responsible for enhancing documentation practices and ensuring compliance with hospital standards.

Requirements

• Graduate of a nursing program; BSN preferred.
• Valid state Registered Nurse license.
• Minimum score of 70% on the Clinical Competency Assessment (CCA).
• At least 5 years of experience in adult acute care, including med/surg, critical care, emergency room, or PACU.
• Strong organizational, analytical, writing, and interpersonal skills.
• Reliable, self-motivated, and approachable.
• Proficient in critical thinking, problem-solving, and deductive reasoning.
• Knowledgeable in pathophysiology and disease processes.
• Basic computer skills with familiarity in Windows-based software.
• Understanding of various disease processes across clinical specialties, anatomy, physiology, and pharmacology.

Nice To Haves

• Utilization review experience (1 year preferred)

Responsibilities

• Complies with the hospital's Performance Standards, Policies, and Behavioral Guidelines.
• Reviews medical records for thoroughness and accuracy in documenting severity of illness (SOI) and quality, utilizing Compliant Documentation Management Program strategies.
• Conducts prompt and precise record reviews.
• Identifies opportunities for enhancing documentation.
• Initiates severity of illness worksheets for inpatients.
• Develops clinically sound documentation clarifications (queries).
• Requests clarifications as needed for SOI, Core Measures, and Patient Safety.
• Communicates effectively and appropriately with physicians.
• Follows up promptly on all cases requiring documentation clarifications.
• Participates in Task Force Meetings (Coder/CDI).
• Collaborates with coders to resolve discrepancies.
• Accurately inputs data into tracking systems.
• Performs other related duties as assigned.

Benefits

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED