Clinical Documentation Specialist

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• Department:
  Health Information Management
• Supervisor: HIM Manager
• Supervises:
  None

The Clinical Documentation Improvement (CDI) Specialist is responsible for enhancing the quality and accuracy of clinical documentation within the healthcare facility. This role involves working closely with healthcare providers to ensure that clinical records accurately reflect patient diagnoses, procedures, and care provided, in accordance with regulatory guidelines. The CDI Specialist will review medical records, identify discrepancies, and collaborate with physicians and other healthcare staff to clarify and improve documentation.

By ensuring thorough and accurate documentation, the CDI Specialist supports improved patient outcomes, compliance with coding and billing regulations, and optimal reimbursement.

Hourly wage range: $36.14 - $51.02, based on experience, education, and internal equity considerations.

• Perform expert-level review of inpatient and observation clinical records within 48 hours of admission, as well as on a daily basis, concurrent with patient stay.
• Identify principal and secondary diagnoses to accurately reflect the patient’s hospital course utilizing ICD-10-CM with appropriate application of coding conventions and guidelines.
• Ensure accuracy of MS-DRG grouping and APC assignments.
• Collaborate with inpatient and observation providers to ensure documentation reflects severity of illness and acuity of care, and identify opportunities for clarification.
• Perform expert-level review of outpatient clinic records and communicate with providers opportunities for improvement of clinical documentation to support medical necessity.
• Communicate with providers at all levels by articulating queries and rationale for queries/requests for clarification, and follow through on all queries and requests for clarification.
• Provide education to healthcare providers to reinforce best practices in clinical documentation, leading to more accurate and complete medical records.
• Collaborate with coding staff to review problematic cases and ensure accurate and appropriate code assignment.
• Review and analyze data to identify trends, variance, and opportunities to improve documentation and documentation review processes. Report findings to HIM Manager.
• Actively participate in interdisciplinary committees to support documentation improvement efforts across the facility. Monitor changes in laws, regulations, and policies affecting clinical documentation to ensure ongoing compliance and best practices.

• RN with 3-5 years of acute care experience OR
• RHIT/RHIA with 3-5 years of inpatient coding experience
• English proficiency (speak, read, write) for safe and effective communication in a healthcare environment.

• CDIP or CCDS Credential, RHIA, RN, CCS
• Basic knowledge of ICD-10 coding and DRG’s

• 80 hours per 2 week pay period
• Monday-Friday, 8:00am-4:30pm
• Hybrid schedule, requiring on-site work at least 3 days per week.

• Paid Time Off accrued on first paycheck
• Medical and Dental Insurance, Vision Discount Plan
• Flexible spending accounts
• Life, accidental death & dismemberment, disability insurance
• Pension Plan (PERA) with a 7.5% company match
• 457(b) retirement plans available
• Tuition Reimbursement
• On-site Continuing Education
• Free on-site parking
• Other benefits include Qualified Bilingual Staff Program, Employee Assistance Program, and savings opportunities such as cafeteria, scrubs, and OTC medication discount from our pharmacy.

Northfield Hospital + Clinics is an independent organization with over 800 employees. We are known for our positive work environment and quality patient care. We provide a full spectrum of services with our Hospital in Northfield, MN and primary and specialty clinics in Northfield, Lakeville, Farmington, Faribault, and Kenyon, plus Urgent Care locations in Northfield and Lakeville.

Mid-Senior level

Full-time

Administrative

Hospitals and Health Care