Senior Hospital Clinical Documentation Improvement Specialist - FT - Day - Clinical Documentation Improvement Lawrenceville NJ

Position Overview

Responsible for optimizing the accuracy, completeness, and clinical integrity of provider documentation. Performs a second level review aimed at improving clinical documentation, coding accuracy and DRG optimization. Supports escalated documentation issues, mentors CDI team members, and collaborates with physicians, coding, and revenue cycle leadership to improve clinical documentation that impacts reimbursement, quality reporting, and patient outcomes.

Minimum Requirements

• RN required, Graduate of an accredited school of nursing program. BSN, preferred.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP), preferred.
• Three or more years’ recent clinical experience in an acute care setting, preferable ICU or Medical/Surgical, or three or more years related coding experience or clinical documentation improvement specialist experience in a hospital setting in clinical documentation improvement in an acute care setting.

Other Credentials

• Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.
• Excellent verbal and written communication skills.
• Working knowledge of all areas of adult medicine.
• Knowledge of pathophysiology and disease process.
• Intermediate computer skills.
• Familiarity with windows-based software programs and encoding software.

Special Training

• Certification as CCDS or CDIP preferred.

Mental, Behavioral and Emotional Abilities

• Ability to work in environment using multiple EMR systems.
• Excellent observation, analytical thinking, and problem-solving skills.
• Ability to learn/develop skills necessary to perform CDI.
• Flexible, dependable and self-directed.
• Ability to work independently.
• Demonstrates ethical conduct.

Reporting Relationships

No

Essential Functions

• Serves as key resource in CDI operational performance, quality initiatives, and organizational documentation improvement strategy.
• Performs advanced second-level reviews of medical records to optimize the accuracy, completeness, and clinical integrity of provider documentation and identify trends to identify gaps in documentation and training opportunities.
• Conducts in-depth reviews prior to final billing of target case populations, place queries if documentation opportunities are identified, and collaborate with the coding team on coding opportunities.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed.
• Proactively identifies issues with reporting of diagnostic testing.
• Collaborates with CDI leadership to review trends related to DRG downgrades, query activity, and revenue cycle opportunities to inform educational content and strategic planning for CDI, HIM Coding, or Provider audiences.
• Delivers targeted provider education on high-impact conditions, documentation pitfalls, and regulatory updates.
• Participate in clinical quality committees and initiatives impacting documentation.
• Provides subject matter expertise to support organizational needs.
• Act as a mentor and resource to CDI Specialists, providing real-time feedback and training.
• Aid in onboarding, competency development, and ongoing education for new staff.
• Collaborate with CDI leadership to refine workflows, policies, and documentation standards and interprets data trends.
• Leverage CDI software for case prioritization, query management, and analytics.
• Periodically review the criteria established for cases triggering a second-level review and recommend updates or modifications to the criteria to assist in identifying areas of opportunity.
• Maintains departmental accuracy and productivity standards.
• Fosters teamwork and collaboration.
• Assists in the appeal process resulting from third-party reviews.

Physical Demands and Work Environment

• Frequent physical demands include: Sitting, Reaching forward, Wrist position deviation, Pinching/fine motor activities, Keyboard use/repetitive motion, Talk or Hear.
• Occasional physical demands include: Standing, Walking, Climbing (e.g., stairs or ladders), Carry objects, Push/Pull, Twisting, Bending, Reaching overhead, Squat/kneel/crawl.
• Continuous Physical Demands Include: Lifting Floor to Waist 15 lbs., Lifting Waist Level and Above 15 lbs.

Usual Work Day

Does not involve supervising employees.

Benefits

• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA)
• Healthcare FSA
• Dependent Care FSA
• Retail Savings and Investment Plan
• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
• Disability Benefits – Long Term Disability (LTD)
• Disability Benefits – Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance
• Voluntary Life Spouse Voluntary Life
• Employee Voluntary Life
• Child Voluntary Life
• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program