Clinical Documentation Integrity Specialist II

About the Role

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.

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.

Qualifications

• RN/Associate's Degree required; BSN preferred in Nursing or a health-related field.
• Current and active Registered Nurse (RN) license required (Kansas Nursing License or current Multi-State Nursing License).
• Certified Clinical Documentation Specialist (CCDS) required.
• JATA training preferred.

Required Experience

• Five years of Clinical Documentation Improvement (CDI) experience required.
• 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.
• Acute care nursing experience in Obstetrics, Labor & Delivery, Mother-Baby, Women's Services, NICU, or related specialties strongly preferred.

Skills

• Excellent verbal and written communication skills with the ability to develop and maintain effective professional relationships.
• Demonstrated ability to communicate effectively with physicians, advanced practice providers, and interdisciplinary healthcare teams.
• Strong organizational, prioritization, and time management skills.
• Ability to manage multiple responsibilities and competing priorities in a fast-paced healthcare environment.
• Proficiency in computer applications, electronic health record systems, CDI software, and related technologies.
• Ability to work effectively with multiple software applications simultaneously.
• Strong critical thinking, clinical reasoning, problem-solving, and decision-making skills.
• Ability to analyze clinical documentation and identify opportunities for improvement.
• Knowledge of pathophysiology, disease processes, clinical treatment modalities, and patient care practices.
• Knowledge of clinical documentation improvement principles and documentation requirements.
• Knowledge of coding concepts, DRG methodology, reimbursement systems, and healthcare quality measures.
• Knowledge of regulatory, compliance, accreditation, and quality reporting requirements.
• Ability to organize, interpret, and present information clearly and concisely.
• Demonstrated ability to learn, develop, and refine clinical documentation improvement skills.
• Dependable, self-motivated, professional, and collaborative.
• Ability to work independently while maintaining strong teamwork and customer service standards.

Benefits

• Benefits from Day One: 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

Schedule

Full-time | Day Shift

Pay

$67,662.40 - $125,860.80