Clinical Documentation Improvement Specialist - Hybrid Remote

City/State:

White Plains, New York

Department:

Health Information Management_4

Work Shift:

Day

Work Days:

MON-FRI

Scheduled Hours:

8 AM-4 PM

Hours Per Pay Period:

75

Pay Rate/Range:

$95,373.14 - $143,059

Job Summary

The CDIS facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Improvement Program (CDIP) process is a key role.

Essential Functions

• 1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors.
• 2. Reviews the medical record for completeness and accuracy for severity of illness (SOI) and quality using the current CDI software and electronic medical record.
• 3. Performs accurate and timely initial and concurrent record review
• 4. Recognize opportunities for documentation improvement
• 5. Facilitates appropriate clinical documentation to support accurate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
• 6. Formulate clinically credible documentation clarifications (queries) to improve clinical documentation and capture of the appropriate principal diagnosis and all comorbidities.
• 7. Request documentation clarifications as appropriate for principal diagnosis, severity of illness, risk of mortality, risk adjustment and quality measures.
• 8. Communicates with physicians, nurse practitioners, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation.
• 9. Timely follow up on all cases and resolution of those with clinical documentation clarifications.
• 10. Collaborate with HIM coding staff to promote complete and accurate clinical documentation and resolve discrepancies and appropriate DRG assignment.
• 11. Communicates with coders and resolves discrepancies
• 12. Conducts post discharge reviews and reconciliation of queries.
• 13. Performs all other related duties as assigned.

Qualifications

• BSN Required or
• Physicians' Assistant degree
• 4-6 years 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU. Required
• Score (minimum of 70%) on the Clinical Competency Assessment (CCA)
• Organizational, analytical, writing and interpersonal skills
• Dependable, self-directed and pleasant
• Critical thinking, problem solving and deductive reasoning skills
• Knowledge of Pathophysiology and Disease Process
• Basic Computer skills – familiarity with Windows based software programs
• Knowledge of disease processes in all clinical specialties, anatomy & physiology and pharmacology and must have the ability to correlate abnormal lab results to disease processes
• Knowledge of official coding guidelines and documentation requirements related to the Inpatient Prospective Payment System
• Knowledge of regulatory environment
• Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments
• Knowledge of Coding Guidelines & Quality Measures
• Current state RN or PA license
• Score (minimum of 70%) on the Clinical Competency Assessment (CCA)

White Plains Hospital Medical Center is an equal employment opportunity employer. White Plains Hospital Medical Center will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.

About Us

White Plains Hospital is a proud member of the Montefiore Health System, serving as its tertiary hub of advanced care in the Hudson Valley. The Hospital is a 292-bed not-for-profit health care organization with the primary mission of providing exceptional acute and preventive medical care to all people who live in, work in or visit Westchester County and its surrounding areas. White Plains Hospital has outpatient medical facilities across Westchester, including multispecialty practices in Armonk, Hawthorne, Larchmont, New Rochelle, Rye Brook, Scarsdale, Somers, Yonkers and Yorktown Heights; and Scarsdale Medical Group locations in Harrison and Scarsdale.

The Hospital is fully accredited by the Joint Commission, and in 2025 received another 5-star rating from the Centers for Medicare & Medicaid Services (CMS) — the highest distinction offered by the federal agency – for the fourth consecutive year. In addition, the Hospital received its third Magnet® designation from the American Nurses Credentialing Center (ANCC), a distinction held by only two percent of hospitals in the country. White Plains Hospital has consistently received the Outstanding Patient Experience Award from Healthgrades®, and in 2025 was awarded an “A” Safety Grade from the Leapfrog Group for the 14th consecutive time.