Clinical Documentation Specialist

As Mount Sinai grows, so does our legacy in high-quality health care.

Since 1949, Mount Sinai Medical Center has remained committed to providing access to its diverse community. In delivering an unmatched level of clinical expertise, our medical center is committed to recruiting and training top healthcare workers from across the country. We offer the latest in advanced medicine, technology, and comfort in 12 facilities across Miami-Dade (including our 674-bed main campus facility) and Monroe Counties, with 38 medical services, including cancer care, 24/7 emergency care, orthopedics, cardiovascular care, and more. Mount Sinai takes pride in being South Florida's largest private independent not-for-profit hospital, dedicated to continuing the training of the next generation of medical pioneers.

Culture of Caring: The Sinai Way

Our hardworking, tight-knit community of more than 4,000 dedicated employees fosters an environment of care and compassion. Each member plays a vital role in our collective mission to deliver excellent healthcare through innovation, education, and research. At Mount Sinai, we take pride in our achievements, aiming to be a beacon of quality healthcare in South Florida. We welcome all healthcare professionals to join our thriving community and contribute to our pursuit for clinical excellence.

Department:

Job Description Summary:

Remote/Hybrid - Florida Residency Required
Clinical Documentation Integrity (CDI) Specialist I/II

The Clinical Documentation Integrity (CDI) Specialist performs concurrent and retrospective reviews of inpatient medical records to ensure accurate, complete, and clinically supported documentation that reflects the severity of illness, quality outcomes, and reimbursement integrity. Utilizing advanced knowledge of ICD-10 coding guidelines, MS-DRG methodology, CC/MCC identification, and clinical documentation standards, this role identifies documentation opportunities, develops compliant provider queries, and collaborates with physicians, HIM coding, Revenue Cycle, Quality, IT, and clinical teams to resolve documentation and DRG discrepancies. The CDI Specialist manages assigned reviews, query follow-up, financial reconciliation, and reporting activities while supporting quality improvement initiatives, documentation integrity, and revenue optimization. At the senior level, the role independently handles complex cases, contributes to departmental projects, analyzes documentation trends, and provides mentorship and guidance to CDI team members.

Position Responsibilities

• Applies ICD-10 coding guidelines appropriately and has an 85% Working DRG accuracy
• Has good working knowledge of all DRG and their structure, as well as CCs and MCCs. Can discern what the impact of a query would be in order to focus efforts efficiently and determine priorities
• Reviews all patient records in his/her assigned unit(s) between 24-48 hours of inpatient admission and subsequently beween 2-3 days until discharge, as needed. Manages approximately 16-20 charts daily
• Recognizes opportunities for documentation improvement by utilizing sound clinical reasoning and critical thinking skills, as well as coding concepts
• Formulates clinically credible queries to physicians and achieves a response rate and agree rate above 85% respectively.
• Mantains excellent rapport and working relationship with physicians, residents, physician assistants, nurse practitioners, nurses, case managers and other healthcare providers
• Mantains query rate of 25-35% of all patient records reviewed
• Follows up on all pending queries on a daily bais until answered and monitors. Manages the Epic query workqueues as well as the 3M 360 pending queries swim lanes regularly
• Has good command of 3M 360 Encompass software and maintains an accurate data input of patient's working DRG and baseline DRG. Records daily review notes and all other notes required within the sofware accurately.
• Responsible for retrospective reviews for quality and revenue projects as assigned
• Properly documents query narrative and notes the expected query response and the actual response including date and location of response in the medical record (what and where).
• Responsible for mentoring and training new employees in conjuction with department Manager
• Reviews the mismatch report periodically to ensure working DRGs are optimal and addresses any discrepancies with HIM coding staff in an effective and timely manner.
• Supports manager in reconciliation of monthly query reports and other financial reports as needed
• Works individual monthly financial report to ensure accounts with financially impacting queries have the proper baseline DRG and that final DRG and working DRG match to ensure reporting is optimal
• Reports accounts with unaswered queries that would have otherwise impacted DRG weight for tracking.
• Provides suport to Rehab team by reviewing potential rehab admissions to ensure they meet CMS compliance criteria and queries Rehab physicians as needed to include supporting diagnoses. Evaluates rehab visits for potential tier improvements by querying physicians for potential qualifying diagnoses.

Qualifications

• Remote/Hybrid - Florida Residency Required

• License/Registration/Certification

  • CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Integrity Practitioner). CCS (Certified Coding Specialist) preferred.

• Education

  • R.N. preferred; Medical School Graduate; Bachelor's Degree

• Experience

  • Critical Care/ Intensive Care patient care experience preferred; medical record (ICD-9) coding and/or prior Clinical Documentation Improvement experience desired

Benefits:

We believe in the physical and mental well-being of our employees and are committed to offering comprehensive benefits that fit their personal needs:

• Health benefits
• Life insurance
• Long-term disability coverage
• Healthcare spending accounts
• Retirement plan
• Paid time off
• Pet Insurance
• Tuition reimbursement
• Employee assistance program
• Wellness program
• On-site housing for select positions and more!

Degree Requirements:

Certification: