Job Description

Location: Steward Health Care
Posted Date: 8/30/2021


The Clinical Documentation Integrity Specialist’s role is to provide clinically based concurrent and retrospective review of all inpatient medical records to access and procure accurate and complete documentation of the patient’s diagnoses and procedures. The Clinical Documentation Integrity Specialist acts as a liaison between medical staff, nursing and coding to ensure the clinical documentation supports and reflects the most appropriate level of services and resources provided. Superior written and oral communication skills coupled with the ability to analyze and critically think is essential.


  • Provides clinically based concurrent review of inpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnoses and procedures.
  • Ensures documentation accurately reflects quality of care, severity of illness and risk of morality to support correct coding, reimbursement and quality initiatives.
  • Proactively contacts physicians or other departments regarding procedures/diagnoses to ensure proper documentation. This includes joining physicians and other clinical staff in educational sessions and “rounds” on the nursing units. Participates, when appropriate, with questions to improve overall documentation of the care being rendered to the patient.
  • Performs initial case reviews and appropriate number of follow-up reviews based on the programs standards.
  • Following –up with the physician responsible for the care of the patient, via the query process, for clarification of clinical significance.
  • Assign the DRG based on coding guidelines/ regulations issued by AHA (Coding Clinic) and CMS.
  • Works in collaboration with the HIM coding department.
  • Prepares and presents educational sessions to physicians on proper documentation.
  • Monitors and participates in performance improvement initiatives.
  • Monitors and participates in performance improvement initiatives.
  • Participates in the planning for assigned inter/intra departmental meetings and presentations
  • Maintains professional competency by keeping abreast of new coding issues and guidelines.
  • Communicates cooperatively on a daily basis with coding specialists and case managers regarding mutual cases. Able to be an approachable liaison to facilitate the achievement of CDI goals.
  • All tasks need to be performed following the Operating Principles of Steward Healthcare. Adheres to system and department compliance policies, and any and all applicable laws and regulations. Performs other duties as assigned.
  • Communications effectively with medical staff and Data Quality Specialists and Coding Manager (as necessary) to acquire, interpret, and transmit accurate diagnostic and procedure information for billing.
  • Keep Program Director informed of potential and/or actual problems identified during the review process, concurrent progress and operation of program.
  • Demonstrates all skills of CDS with <%5 error rate.
  • Attains Clinical Documentation Specialist certification through ACDIS or AHIMA.
  • Volunteers for special projects in CDI such as developing physician education materials or CDI TIPS of the Month Education.
  • Continues with CDI education and query opportunities.


  • Must possess strong organizational skills.
  • Clinical Documentation Improvement with ICD-10 experience


  1. Education: Bachelor’s degree in a clinical or coding study is preferred
  2. Experience (Type & Length): Minimum of 5 years acute Medical/Surgical nursing experience preferred. Minimum of 2 years’ experience in CDI I role
  3. Certification/Licensure: RN with current licensure. Certification in Clinical Documentation preferred.
  4. Software/Hardware: Proficient knowledge of Microsoft applications, including Word, Excel and PowerPoint. and proficiency in EMR applications, CDI and coding software

Application Instructions

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