Clinical Documentation Improvement (CDI) Specialist
SUNY Downstate Health Sciences University · Brooklyn
The Department of Health Information Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Clinical Documentation Improvement (CDI) Specialist.
Job Summary
Reporting to the CDI Manager and Director of Health Information Management, the CDI Specialist is responsible for reviewing inpatient medical records to ensure that clinical documentation accurately and comprehensively reflects the patient's clinical condition, severity of illness, risk of mortality, and services provided throughout hospitalization.
Working collaboratively with physicians, residents, advanced practice providers, nursing staff, coding professionals, and other interdisciplinary healthcare teams, the CDI Specialist identifies opportunities for documentation clarification and improvement to support accurate clinical coding, appropriate reimbursement, regulatory compliance, and quality reporting.
Key Responsibilities and Duties
- Conduct concurrent reviews of inpatient medical records upon admission and throughout hospitalization for designated patient and payer populations, including Medicare, Medicaid, and commercial insurance.
- Evaluate clinical documentation for accuracy, completeness, specificity, and consistency with the patient's clinical presentation, treatment, and care.
- Identify documentation gaps, inconsistencies, or opportunities for clarification related to diagnoses, comorbidities, complications, severity of illness, and risk of mortality.
- Communicate with attending physicians, residents, advanced practice providers, and other clinical staff to obtain timely clarification of clinical documentation through appropriate verbal and written queries.
- Collaborate with Health Information Management coding professionals to ensure that principal diagnoses, secondary diagnoses, and relevant comorbidities are accurately and completely documented.
- Apply clinical knowledge, critical thinking, and analytical reasoning to assess medical records and identify documentation improvement opportunities.
- Support accurate clinical coding, quality reporting, and reimbursement through improved documentation practices and an understanding of applicable coding and Medicare reimbursement methodologies.
- Develop and deliver formal and informal education to physicians, nursing staff, and other clinical providers regarding clinical documentation requirements, best practices, and identified improvement opportunities.
- Collaborate with physician leadership and departmental stakeholders to develop tools, educational resources, and processes that support consistent and effective clinical documentation.
- Conduct timely follow-up with providers regarding outstanding documentation clarification requests and ensure appropriate resolution.
- Participate in departmental and organizational quality improvement initiatives designed to strengthen documentation accuracy, clinical data integrity, and operational efficiency.
- Maintain effective working relationships with physicians, nursing leadership, coding professionals, and interdisciplinary healthcare teams to promote a collaborative documentation improvement environment.
- Utilize electronic medical records, CDI applications, and Microsoft Office applications to perform documentation reviews, communicate findings, and support departmental activities.
- Maintain the confidentiality and security of patient information in accordance with HIPAA, institutional policies, and applicable regulatory requirements.
- Maintain professional competency through continuing education, professional development, and participation in relevant training programs.
- Demonstrate professionalism, accountability, cultural competence, and adherence to SUNY Downstate's institutional mission, values, and standards of conduct.
- Perform other related duties as assigned.
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