Clinical Documentation Improvement Analyst

Location: Geneva

POSITION

PURPOSE:

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 preferredCDI 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/CernerGENERAL 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 Abstraction and Analytics) reporting tools.

Designs, develops, and maintains dashboards that monitor key CDI, quality, and documentation performance indicators.

Analyzes documentation trends, opportunities, and gaps to identify areas for improvement.

Assists with documentation-related quality measure requirements and reporting initiatives.

Performs root cause analysis of documentation, coding, and data integrity variances.

Translates data findings into actionable recommendations for providers, leadership, quality, and operational teams.

Prepares and presents CDI performance reports to leadership, quality, informatics, and revenue cycle stakeholders.

Monitors and evaluates the impact of documentation practices on quality reporting, regulatory reporting, and organizational performance.
3. Provides leadership and support for documentation-related workflow optimization, system design, and clinical informatics initiatives.

Serves as the CDI lead for EHR documentation workflow design, optimization, and…