Job Summary: The Clinical Documentation Improvement (CDI) Specialist plays a critical role in enhancing the quality, accuracy, and completeness of clinician documentation within the ISNP Clinical Company. This position is dedicated to improving patient care and ensuring compliance with regulatory standards by collaborating closely with healthcare providers, educating them on documentation best practices, and delivering constructive feedback. The CDI Specialist will contribute to the overall efficiency and effectiveness of clinical operations, enabling the organization to provide high-quality healthcare services. The CDI Specialist is a remote position. Key Tasks and Responsibilities: Review and analyze clinician documentation for accuracy and completeness, ensuring compliance with coding and regulatory guidelines. Collaborate with clinical staff to identify areas for improvement in documentation practices and develop strategies to address them. Provide ongoing education and training sessions for clinicians on best practices for clinical documentation and coding requirements. Deliver timely, constructive feedback to clinicians regarding documentation deficiencies and suggest improvements. Assist in developing and implementing documentation improvement initiatives to enhance overall quality and performance metrics. Monitor and evaluate documentation trends and performance indicators, reporting findings to management for continuous improvement. Serve as a subject matter expert on clinical documentation standards, coding guidelines, and regulatory requirements. Participate in interdisciplinary team meetings and contribute to quality improvement projects as needed. Supervisory Responsibilities: There are no supervisory responsibilities for this position. Credentials & Coverage: AAPC or AHIMA certification(s): CPC or COC plus CRC, CPMA, CDEO, CCDS, CDIP or LPN/RN with minimum of 2 years of Clinical documentation Improvement experience with ability to obtain certification within 12 months of hire Valid state driver’s license with a good driving record and proof of automobile insurance required. [all roles] Auto liability insurance coverage per minimum required by home state. Education and Training: Bachelor’s degree in Nursing, Health Information Management, or a related field required; Master’s degree preferred. Certification as a Clinical Documentation Specialist (CDS) or similar credential is strongly preferred (e.g., CCDS, CDIP). Ongoing education in relevant healthcare regulations, coding practices, and documentation standards. Experience working in and developing CDI programs can be substituted for education requirements. Knowledge and Experience: Minimum of 3 years of clinical experience in a healthcare setting, with a strong understanding of clinical documentation and coding processes. Minimum of 2 years of experience as a coding auditor/educator and/or clinical documentation improvement specialist Familiarity with Electronic Health Record (EHR) systems and clinical documentation software. Knowledge of healthcare regulations, including Medicare/Medicaid requirements and other relevant regulatory frameworks. Excellent communication and interpersonal skills, with the ability to effectively educate and engage clinical staff. Strong analytical skills and attention to detail, with the ability to assess documentation for accuracy and compliance. Experience in conducting training sessions and providing feedback in a constructive manner. Ability to execute multiple tasks and adhere to strict deadlines in a fast-paced, changing, environment required. Team working skills, persistence, high energy, initiative, and creativity. Hands-on approach, with high attention to detail and accuracy required. Strong communication and interpersonal skills, including the ability to interact effectively with all areas and levels required. Proactive, assertive, and creative, approach to problem solving required. Team-oriented & flexible, able to work closely with all levels of management required.
