Clinical Documentation Integrity Specialist II

AdventHealth • Mission, TX

1d • Remote

About The Position

Responsible for facilitating and obtaining accurate, complete, and compliant physician documentation to support the severity of illness, risk of mortality, quality outcomes, and complexity of Obstetrics and NICU patient care. Educates physicians, advanced practice providers, nursing staff, care management, and other healthcare professionals regarding documentation standards, regulatory requirements, and clinical documentation improvement (CDI) practices. Ensures adherence to organizational policies, regulatory guidelines, departmental goals, and performance standards while promoting documentation integrity and compliance. Contributes to the efficiency and effectiveness of clinical documentation processes through collaboration, critical thinking, and continuous improvement efforts.

Requirements

• Kansas Nursing License or current Multi-State Nursing License
• 5 years of Clinical Documentation Integrity (CDI) experience involving Obstetric and/or Neonatal Intensive Care Unit (NICU) patient populations, including review of Obstetric and NICU cases
• Five years of Clinical Documentation Improvement (CDI) experience required.
• Current and active Registered Nurse (RN)
• Certified Clinical Documentation Specialist (CCDS) required.

Nice To Haves

• BSN Preferred
• Acute care nursing experience in Obstetrics, Labor & Delivery, Mother-Baby, Women's Services, NICU, or related specialties strongly preferred.
• JATA training preferred.

Responsibilities

• Facilitates clinical documentation improvement activities to ensure accurate representation of patient acuity, severity of illness, risk of mortality, and quality outcomes.
• Reviews concurrent medical records for completeness, accuracy, compliance, and documentation opportunities.
• Identifies opportunities for documentation improvement through analysis of clinical indicators, medical necessity, and patient care documentation.
• Develops and communicates clinically supported documentation clarifications to physicians, advanced practice providers, and other members of the healthcare team.
• Initiates and formulates CDI severity worksheets and documentation queries that support compliant documentation practices.
• Reviews and reconciles documentation related to severity of illness (SOI), risk of mortality (ROM), patient safety indicators (PSI), hospital-acquired conditions (HAC), hierarchical condition categories (HCC), and other quality measures.
• Accurately enters and maintains CDI data within designated software systems, supporting reporting and performance metrics.
• Collaborates with physicians, nursing staff, HIM professionals, coders, and other healthcare team members to improve documentation quality and accuracy.
• Works with Health Information Management staff to resolve DRG assignment discrepancies and coding-related documentation issues.
• Conducts timely follow-up reviews on concurrent cases and prioritizes cases requiring clarification resolution.
• Educates physicians, advanced practice providers, nursing staff, and other healthcare professionals regarding documentation requirements, regulatory guidelines, and best practices.
• Maintains physician engagement and supports timely responses to documentation clarification requests.
• Participates in departmental meetings, educational initiatives, performance improvement activities, and process improvement efforts.
• Assists with orientation, training, mentoring, and precepting of new team members.
• Completes annual educational projects and presentations for the CDI team.
• Maintains documentation integrity and compliance with organizational, regulatory, and accreditation requirements.
• Performs other duties as assigned.

Benefits

• Medical, Dental, Vision Insurance
• Life Insurance
• Disability Insurance
• Paid Time Off from Day One
• 403-B Retirement Plan
• 4 Weeks 100% Paid Parental Leave
• Career Development
• Whole Person Well-being Resources
• Mental Health Resources and Support
• Pet Benefits

What This Job Offers

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