Chambersburg, PA | Nursing | Tracking Code: 81872

Clinical Documentation Integrity Specialist II - Day

Renee Kegarise
Renee Kegarise
Sr. Talent Acquisition Consultant

Full Time (80 Hours Biweekly)

Day Shift

CCDS or CDIP Certification, Required


Job Description

Under the general supervision of the Manager-Clinical Documentation Integrity, reviews medical record documentation to facilitate the accurate representation of the severity of illness, patient acuity and risk of mortality for a specified patient population. Obtains appropriate clinical documentation through extensive interaction with physicians, healthcare providers and Health Information Management (HIM) professionals. Actively participate in meetings and education of staff related to Clinical Documentation Integrity (CDI).


Duties and Responsibilities

  1. Facilitates CDI education to physicians and clinicians by creating timely presentations that can be shared by Clinical Documentation Specialist (CDS), while minimizing the non-productive time of the team.
  2. Audits CDS reviews for quality and compliance and validates queries for consistency and impact. Shares findings with Manager.
  3. Reviews and updates policies and procedures.
  4. Serves as a subject matter expert and mentor for the CDI team and supports new hires during and after the orientation period.
  5. Assesses and completes the retrospective quality needs of the medical record to ensure accuracy and integrity.
  6. Facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients by completing accurate and timely record reviews.
  7. Improves the overall quality and completeness of clinical documentation by performing admission and continued stay reviews.
  8. Demonstrates knowledge of Diagnosis Related Group (DRG) payer issues, documentation opportunities, and clinical documentation requirements.
  9. Demonstrates knowledge of Medicare, general understanding of hospital-based quality initiatives, and regulatory environment.
  10. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
  11. Completes timely follow up on all cases, especially those with clinical documentation clarifications and ensures points of clarification have been recorded in the patients’ medical record.
  12. Formulates ethical and clinically credible documentation clarifications.
  13. Processes discharges by updating the CDI software to reflect any changes in status, procedures, and treatments, and confers with clinicians to finalize diagnoses.
  14. Accurately inputs data into the CDI software.
  15. Effectively and appropriately communicates with physicians and healthcare providers.
  16. Reviews clinical issues with coding staff to assign a working DRG and reconcile final DRG.
  17. Serves as a member of the CDI Task Force.
  18. Educates all internal customers on compliant documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies.
  19. Prepares educational materials for presentation at meetings, physician grand rounds, interdisciplinary rounds, physician staff meetings, and participates in new provider orientations.


  • Minimum Experience:
    • 2 years Clinical Documentation Integrity experience
  • Minimum Education:
    • Bachelor’s Degree
  • Required Certification:
    • CCDS or CDIP; RN, MD, DO or APP (PA or CRNP) with current license in PA


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