Clinical Documentation Integrity Specialist II

Responsible for facilitating and obtaining accurate, complete, and compliant physician documentation to support severity of illness, risk of mortality, quality outcomes, and complexity of patient care. Educates physicians, advanced practice providers, nursing staff, care management, and other healthcare professionals on documentation standards, regulatory requirements, and clinical documentation improvement practices. Supports documentation integrity, compliance, and continuous improvement through collaboration with interdisciplinary teams.

Essential Functions

• Facilitate clinical documentation improvement activities to ensure accurate representation of patient acuity, severity of illness, risk of mortality, and quality outcomes.
• Review concurrent medical records for completeness, accuracy, compliance, and documentation opportunities.
• Identify opportunities for documentation improvement through analysis of clinical indicators, medical necessity, and patient care documentation.
• Develop and communicate clinically supported documentation clarifications to physicians, advanced practice providers, and other healthcare team members.
• Initiate and formulate CDI severity worksheets and documentation queries that support compliant documentation practices.
• Review and reconcile documentation related to SOI, ROM, PSI, HAC, HCC, and other quality measures.
• Enter and maintain CDI data within designated software systems to support reporting and performance metrics.
• Collaborate with physicians, nursing staff, HIM professionals, coders, and other team members to improve documentation quality and accuracy.
• Work with Health Information Management staff to resolve DRG assignment discrepancies and coding-related documentation issues.
• Conduct timely follow-up reviews on concurrent cases and prioritize cases requiring clarification resolution.
• Educate clinicians and healthcare staff on documentation requirements, regulatory guidelines, and best practices.
• Support physician engagement and timely responses to documentation clarification requests.
• Participate in departmental meetings, educational initiatives, performance improvement activities, and process improvement efforts.
• Assist with orientation, training, mentoring, and precepting of new team members.
• Complete annual educational projects and presentations for the CDI team.
• Maintain documentation integrity and compliance with organizational, regulatory, and accreditation requirements.