• Develop high-quality educational materials, including presentations, training decks, and supporting resources • Review and approve medical content to ensure alignment with internal standards and regulatory requirements • Support Train-the-Trainer programs by enabling clear communication of clinical content to physicians • Work with data analysts to ensure external materials present clinically relevant and interpretable data • Build compelling, evidence-based narratives that strengthen the impact of educational content • Translate complex scientific literature into concise, practical insights for education purposes • Maintain a structured and searchable reference library of clinical evidence and materials • Contribute to initiatives that demonstrate the clinical value and application of medical technologies

• Facilitate improvements in clinical documentation quality, completeness, and accuracy to support patient care and reimbursement outcomes. • Analyze clinical records and identify documentation opportunities related to severity of illness, risk of mortality, and coding accuracy. • Assign working DRGs for inpatient admissions and support appropriate code assignment. • Collaborate with physicians, Nurse Case Managers, and multidisciplinary care teams to obtain complete and accurate clinical documentation. • Query providers to clarify incomplete, conflicting, or ambiguous documentation using approved processes. • Perform clinical record abstracting and data collection to support reimbursement, quality initiatives, and outcome reporting. • Educate physicians and care teams on documentation standards, coding updates, MS-DRG changes, and coding guidelines. • Ensure the accuracy and integrity of medical record data prior to billing and claims submission. • Partner with Patient Accounting and coding teams to resolve reimbursement and documentation-related issues. • Support quality management and continuous improvement initiatives through data analysis, education, and documentation integrity efforts.

• The CDI Specialist is responsible for comprehensive secondary clinical chart reviews to identify potential missed opportunities for documentation clarification. • Collaborates closely with Coders, Coding Educators, Coding Quality Auditors, Case managers, Quality Department and Providers to assure documentation is clinically appropriate. • Conducts daily, concurrent review of inpatient records on assigned unit(s) to ensure complete and accurate physician and or clinician documentation is present at the time of discharge. • Reviews daily admissions to assigned unit, perform initial code assignment for a working DRG and complete CDI software data entry for initial and follows up case reviews and submit to Program Assistant. • Updates “working DRG” as documentation supports, or physician query answer supports a change in the DRG assignment. • Communicates to the CDI Coordinator when volume of daily review assignments is too high or low so that CDI Coordinator can assist in adjusting review assignments amongst the team. • Initiates compliant physician queries when documentation is confusing, ambiguous, or missing and follows up with MD to seek immediate response to query.

Role Description Improves the overall quality and completeness of medical documentation; facilitates enhancements to clinical documentation through extensive interaction with physicians, nursing staff, case managers, other patient caregivers, and medical records coding staff to ensure that the appropriate reimbursement is received for the level of service rendered to all inpatients; ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes; educates all members of the patient care team on an ongoing basis. Essential Responsibilities - Facilitate appropriate clinical documentation through concurrent, prospective, and retrospective medical record review (30%) - Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses and ancillary staff based on knowledge of coding and HCC guidelines, documentation strategies, and clinical documentation requirements (25%) - Work collaboratively with coding professionals to assure documentation of diagnoses and comorbidities are a complete reflection of the patient's clinical status and care (10%) - Formulate credible clinical documentation clarifications to improve clinical documentation (10%) - Educates all internal customers on compliant documentation responsibilities, coding, and reimbursement issues, as well as performance improvement methodologies (15%) - Performs other duties as assigned or required (10%) Qualifications - Minimum: - High school/ GED - Bachelor's Degree in Nursing OR Relevant experience and/or education as determined by the company in lieu of bachelor's degree - 5 years in a nursing role - Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC) - Preferred: - Experience in Clinical Documentation Integrity (CDI) - Experience in Coding - Knowledge of ICD 10 and HCC coding guidelines - Knowledge of Electronic Medical Record (Epic) - Knowledge of Encoder (3M 360 Encompass) - Excellent communication skills - Critical thinking skills - Certified Coding Specialist (CCS) - Certified Outpatient Clinical Documentation Improvement Specialist (CCDS-O) - Certified Clinical Documentation Improvement Specialist (CCDS) - Certified Clinical Documentation Improvement Professional (CDIP) Company Description