Clinical Documentation Specialist

Clinical Documentation Specialist

• Salisbury, MD
• TidalHealth Corporate
• Health Information Management
• Full Time - Monday - Friday - 6:00 am to 2:30pm
• Req #: 37745
• $80,724.80- $125,112.00 / Annually

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Why work at TidalHealth?

Join a triple A rated team where clinical excellence meets a coastal lifestyle. At TidalHealth, you'll be part of an award-winning network spanning Maryland and Delaware, recognized by the Leapfrog Hospital Safety Guide for our unwavering commitment to patient care. Whether your expertise lies in specialized clinical fields like neurosurgery, academic mentorship through our graduate medical programs, or the critical professional and support roles that keep our network thriving, we provide the tools and tuition assistance you need to excel.

Clinical Documentation Specialist Position Summary

The Clinical Documentation Integrity (CDI) Specialist ensures accurate and complete provider-based clinical documentation at TidalHealth. This position analyzes patients clinical status, treatment plans, and medical history to identify documentation improvement opportunities. The role involves thorough chart reviews and collaboration with providers, nurses, consultants, and HIM coding staff to ensure proper reimbursement and accurate clinical data. CDI Specialists audit and monitor key quality indicators such as MHAC/PPCs, PSIs, HACs, and mortality reviews. The Specialist works closely with healthcare teams to ensure compliance with coding standards and regulatory requirements. The CDI Specialist also communicates with providers using verbal and electronic queries to clarify or improve documentation in line with AHIMA guidelines. The Specialist utilizes ICD-10 coding guidelines and applies the guidelines during documentation evaluations. The role includes developing tools and education plans to support accurate provider documentation. CDI Specialists help design workflows for documentation improvement and provide training for staff and new employees.

Education

• Bachelor's degree in nursing (BSN) is required, or relevant clinical CDI experience may be considered.

Required License and/or Certifications

• Licensed as a Registered Nurse (RN) in the state of residency
• Certified Clinical Document Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP) is required.
• CCS, RHIT or RHIA is preferred.

Required experience:

• Minimum of one (1) year in inpatient coding and/or CDI experience
• Previous experience utilizing Microsoft Office products and EMR

Preferred Experience

• Experience in an acute care health facility
• Previous medical record coding/documentation auditing experience
• Experience with APR DRG & MS-DRG payment systems
• Experience with ICD10 coding methodology, coding guidelines and Clinical documentation integrity programs
• Previous experience with auditing quality measures - PSIs, HACs, Mortality, and MHAC/PPCs.
• Experience with EPIC and 3m 360/CDI Engage One

Clinical Documentation Specialist Work Schedule

• Primarily Day shift Monday - Friday.
• Hybrid- Remote position
• Evening and weekend work as needed.

Clinical Documentation Specialist Benefits

Benefits: We provide a robust benefits suite for our eligible team members (36+ hours for 12-hour shifts; 37.5+ hours for standard shifts):

• Health: Medical (including HSA), Dental, Vision, & Prescription
• Wealth: Matching 403(b), Healthcare FSAs, & Dependent Care FSAs
• Growth: $5,000 Tuition Assistance & Certification support
• Balance: Generous PTO and Holidays, Onsite Child Care, Pet Insurance
• Income Protection & Leave: Employer-Paid Short-Term Disability, Paid Leave Program, & Long-Term Disability (LTD for FT)
• Life & Security: Employer-paid Life and additional voluntary benefits such as Accident, Critical Care, additional Life, and more

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