Clinical Document Improvement Specialist

NY United Health Services•Binghamton, NY

12d•Onsite

About The Position

The Clinical Documentation Improvement (CDI) Specialist – CDI-coder is responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure complete, accurate, and compliant clinical documentation. This role focuses on supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity. This role works closely with providers, coders, and quality teams to clarify documentation and support accurate data capture for clinical, financial, and regulatory reporting.

Requirements

RHIT certification with an Associate degree in HIT
Minimum 2–5 years of inpatient hospital coding experience

Nice To Haves

RHIA certification with a Bachelor’s Degree in HIT
RHIA certification
CCS (Certified Coding Specialist) – AHIMA-preferred
CIC (Certified Inpatient Coder)-AAPC-preferred
CCDS (Certified Clinical Documentation Specialist)–ACDIS- preferred

Responsibilities

Performing concurrent and retrospective reviews of inpatient medical records
Ensuring complete, accurate, and compliant clinical documentation
Supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity
Working closely with providers, coders, and quality teams to clarify documentation
Supporting accurate data capture for clinical, financial, and regulatory reporting