Clinical Documentation Improvement Analyst

Clinical Documentation Improvement Analyst

Fillmore County Hospital - Geneva, NE 68361

Position Type Full Time Job Shift Day

The purpose of the Clinical Documentation Improvement (CDI) Analyst position is to advance clinical documentation integrity through a combination of concurrent review, data analytics, and informatics workflow optimization. This role ensures the accuracy, completeness, and usability of clinical documentation to support quality outcomes, regulatory compliance, reimbursement optimization, and organizational performance within the Critical Access Hospital environment.

Qualifications:

• Graduation from an accredited healthcare program required Bachelor's degree in Healthcare, Health Information Management, Nursing, or related field preferred Current valid healthcare license (or compact license), RHIA, RHIT, or equivalent credential preferred CDI certification (CCDS or CDIP) required or willingness to obtain within an established timeframe Additional certification in informatics, data analytics, quality, or healthcare compliance preferred Working knowledge of clinical documentation standards, coding principles, reimbursement methodologies, quality reporting, and regulatory requirements Strong analytical, critical thinking, communication, and problem-solving skills Experience with Electronic Health Records (EHR), reporting systems, and healthcare analytics tools preferred, preferably Oracle Health/Cerner

General Requirements:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The requirements listed below are representative of the knowledge, skill, and / or ability required:
Ability to add, subtract, multiply, and divide Ability to generate, read, interpret, and take action as it relates to basic financial statements, national and state regulations, safety rulings, operational and maintenance and organizational policies / procedures Ability to write reports and correspondence Ability to effectively present information to patients, families, employees, health care providers, etc... Ability to work cooperatively and communicate effectively to maintain good working relationships with staff and health care providers Ability to work with skill in identifying problems;

making frequent decisions regarding method of performance

Equipment, Tools, Materials:
Calculator Computer and printer Fax and copy machine General office materials/supplies Information Systems Telephone system

Security/Access:
Will have access to the facility 24 hours a day. Will have access to confidential information abiding by the organizations privacy policies and regulations concerning this information.

Essential

Job Duties and Responsibilities
1. Provides clinical documentation improvement services through concurrent and retrospective review of patient records to ensure accurate, complete, and compliant clinical documentation.
• Performs concurrent and retrospective review of inpatient, swing bed, observation, and other applicable encounters.
• Identifies opportunities to improve documentation specificity, severity of illness, risk of mortality, and overall clinical accuracy.
• Initiates, tracks, and manages compliant provider queries with a focus on clinical clarity and documentation integrity.
• Collaborates directly with providers to ensure timely and accurate documentation of patient conditions, treatments, and outcomes.
• Reviews documentation for consistency, completeness, and compliance with established documentation standards.
• Serves as the organizational subject matter expert for clinical documentation integrity, documentation standards, and best practices.
• Works collaboratively with coding, quality, and clinical teams to ensure documentation accurately reflects the care provided.

2. Provides advanced analytics, reporting, and performance monitoring to evaluate and improve the effectiveness of the Clinical Documentation Improvement program.
• Leads the development, maintenance, and ongoing enhancement of DA2 (Data…