Overview
Help ensure every patient story is told accurately and completely.
The Professional Billing (PB) Clinical Documentation Integrity Specialist (CDIS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity and acuity, risk profiles and professional fee billing. The CDIS primarily assists providers in capturing the clinical documentation needed to accurately reflect patient acuity. The PB CDIS will focus on pre-visit provider support, post-visit provider review, and collaboration and education with providers.
Responsibilities
Key Responsibilities
• Conducts pre-visit chart reviews to identify opportunities for accurate documentation, including HCC recapture, validation of suspect diagnoses, and identification of new diagnosis opportunities based on clinical indicators
• Performs post-visit documentation reviews to identify gaps, ensure accurate reflection of provider work effort, and support appropriate E/M leveling and patient acuity
• Evaluates patient history, chronic conditions, and treatment plans to ensure documentation supports medical decision-making and coding accuracy
• Collaborates with providers, coders, population health, and value-based care teams to improve documentation quality and alignment with organizational goals
• Provides education and real-time feedback to providers, including 1:1 coaching, to enhance documentation accuracy and compliance
• Develops and delivers training programs and educational resources to support improved documentation and coding practices
• Maintains up-to-date knowledge of coding guidelines, regulatory requirements, and CDI best practices to ensure compliance
• Serves as a subject matter expert in clinical documentation integrity, offering guidance on documentation standards and regulatory interpretation
• Supports a collaborative team environment by fostering communication, knowledge sharing, and cross-functional partnership
• Monitors CDI performance metrics and utilizes data-driven insights to identify trends, track outcomes, and drive continuous improvement
• Manages multiple priorities while maintaining accuracy, attention to detail, and adherence to program goals
Qualifications
Minimum Education and Experience Requirements
• Associate degree in a healthcare-related field required
• Graduate of an accredited school of nursing with a current Registered Nurse (RN) license in the State of Florida, OR Advanced Medical Practitioner, OR International Medical Graduate (IMG)
• Minimum of three (3) years of recent clinical experience in an acute care hospital setting
• Working knowledge of healthcare regulations, clinical documentation standards, and coding practices
• Experience conducting audits, quality assurance activities, and documentation reviews
• Strong collaboration skills with clinical providers, coding teams, and interdisciplinary stakeholders
• Demonstrated ability to develop and deliver staff education and training
• Strong critical thinking skills with the ability to identify clinical indicators supporting patient acuity and documentation clarification
• Proven ability to manage multiple priorities, work independently, and maintain attention to detail in a fast-paced environment
• Experience working with electronic medical records (Epic preferred)
• Proficiency in Microsoft Office applications (Excel, Word, PowerPoint)
Preferred Qualifications
• Certified Clinical Documentation Specialist (CCDS)
• Experience in Utilization Management, Case Management, Quality Improvement, or Inpatient Coding
Licensure/Certification/Registration (Required)
• One of the following required:
– Registered Nurse (RN)
– Licensed Practical Nurse (LPN)
Motor Vehicle Designation
• This position may require operation of a vehicle for business purposes as a non-frequent driver