Clinical Documentation Informatics Specialist

FMOLHS • Baton Rouge, LA

2d

About The Position

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

The specialist contributes to concurrent and retrospective reviews, physician queries, audits, metric analysis, education, reporting, and CDI technology and workflow support. The role collaborates with CDI leadership and staff, coding professionals, physicians, departments, vendors, and other organizational partners, while following applicable compliance, legal, and organizational requirements.

Requirements

• Five years of combined experience in 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 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

• Perform concurrent and/or retrospective CDI reviews of acute inpatient medical records 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 designated program measures; assist with monitoring and tracking CDI processes and outcomes.
• Operate within Medicare and Medicaid Services compliance guidelines and follow applicable laws, corporate compliance policies, reporting requirements, accrediting standards, and organizational expectations.
• Collaborate with CDI leadership and staff, coding professionals, physicians, departments, vendors, and external partners on CDI initiatives, special projects, and process improvement activities.
• Assist with problem solving, process improvements, implementation of new processes, and ongoing CDI program support.
• Serve as a liaison among CDI operations, coding, information systems, vendors, and organizational stakeholders to support CDI technology, workflows, and processes, as directed by CDI leadership.
• Assist in designing, developing, implementing, and testing workflows, tipsheets, educational materials, query templates, 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 CDI 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