Clinical Documentation Informatics Specialist

FMOLHS • Baton Rouge, LA

1d

About The Position

The Clinical Documentation Informatics Specialist, also referred to as CDI Coordinator, works under the guidance of CDI leadership to assist with clinical documentation initiatives for a hospital or health system. The role supports CDI programs, special projects, process implementation, and continuous process improvement. It reviews medical records to help ensure physician documentation is clear and specific so records can be coded accurately, and serves as a CDI resource for Clinical Documentation Specialists, physicians, CDI leaders, and other stakeholders.

The position conducts concurrent and/or retrospective reviews of acute inpatient records, places physician queries to clarify principal diagnoses or secondary conditions, and contributes to audits, metrics, reports, education, workflow development, and CDI technology support. It collaborates with CDI leadership and staff, coding professionals, physicians, departments, vendors, and other partners to support documentation integrity and organizational objectives.

Requirements

• Five years of combined experience in either clinical nursing and Clinical Documentation Integrity (CDI), or acute care inpatient coding and CDI.
• Experience in CDI auditing, CDI secondary-level reviews, and/or CDI metric analysis.
• Graduate of an accredited school of nursing, or an Associate’s degree in Health Information Management (RHIT) with two years of applicable experience, or a Bachelor’s degree in Health Information Management.
• Active RN license or Certified Coding Specialist (CCS) credential.

Responsibilities

• Review acute inpatient medical records concurrently and/or retrospectively for clarity and specificity of physician documentation.
• Place queries in the medical record requesting physician clarification of the principal diagnosis or secondary conditions.
• Serve as a CDI resource to physicians, CDI staff, coders, and other stakeholders on documentation improvement initiatives, workflows, and best practices.
• Perform CDI audits to identify documentation and coding trends or problem areas.
• Collect, analyze, and/or prepare CDI metrics, documentation trends, and other program measures to support process improvement.
• Assist with monitoring and tracking CDI processes and related outcomes.
• Follow applicable compliance guidelines, laws, policies, reporting requirements, accrediting body standards, and organizational expectations; use ethical decision-making.
• Collaborate with CDI leadership, CDI staff, coding professionals, physicians, departments, vendors, external partners, and other stakeholders on CDI initiatives and process improvements.
• Assist with problem solving, implementation of new processes, and ongoing process support.
• Serve as a liaison among CDI operations, coding, information systems, vendors, and organizational stakeholders for CDI technology, workflows, and processes, as directed by CDI leadership.
• Assist in designing, developing, implementing, and testing workflows, tipsheets, educational materials, query templates, CDI reference tools, and special project content.
• Assist CDI leadership with developing and maintaining reports, audits, dashboards, tracking tools, and educational resources.
• Assist with monitoring and reporting program performance through metrics, audit findings, and documentation improvement indicators.
• Perform designated CDI audits to help identify and address educational opportunities for CDI specialists and coders.
• Assist with testing, implementation, optimization, and ongoing support of CDI software, reporting tools, workflows, and system enhancements.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree