Join Palestine Regional Medical Center in Palestine, TX, a 150-bed hospital that has recently earned the prestigious Leapfrog “A” Safety Grade, the Platinum Award for quality from parent-company ScionHealth, and certification as a Chest Pain Center and Level IV Trauma facility. Palestine Regional provides a range of comprehensive care, including the latest in diagnostic, therapeutic, and rehabilitative services, both on an inpatient and outpatient basis. Palestine Regional is an integral part of the local community, giving you the chance to grow your career while making a real impact close to home.

Job Summary

The Clinical Documentation Integrity (CDI) Specialist is responsible for improving the overall quality, accuracy, and completeness of clinical documentation in the medical record. Through concurrent review and collaboration with physicians, nurses, coders, and other healthcare team members, the CDI Specialist ensures that documentation reflects the true severity of illness, risk of mortality, and complexity of care. This position supports compliance, quality initiatives, and reimbursement through accurate coding and reporting.

Essential Functions

• Perform concurrent reviews of inpatient records to identify opportunities for clarification, specificity, and documentation completeness.
• Initiate and follow up on provider queries in accordance with official coding and organizational standards.
• Abstract clinical data to support coding and DRG accuracy.
• Educate physicians and clinical staff on documentation best practices and regulatory requirements.
• Review documentation for Present on Admission (POA), Hospital-Acquired Conditions (HACs), and other quality indicators.
• Collaborate with case management, quality, compliance, and HIM teams to support clinical accuracy and financial integrity.
• Analyze and report trends related to documentation improvement opportunities and query response rates.
• Maintain current knowledge of CMS regulations, IPPS, AHA Coding Clinics, and industry guidelines.
• Assist with documentation audits and performance improvement initiatives.
• Present educational sessions to providers and staff on clinical documentation topics.
• Uphold ethical, legal, and regulatory standards related to patient privacy and coding practices.

Knowledge/Skills/Abilities/Expectations

• In-depth understanding of clinical care delivery, coding systems (ICD-10, MS-DRG), and documentation regulations.
• Excellent written and verbal communication skills.
• Ability to engage physicians and interdisciplinary teams in a collaborative, educational manner.
• Proficient in EMR systems and data analytics tools.
• Strong attention to detail, organizational skills, and independent judgment.
• Ability to manage multiple tasks and meet documentation timelines.

Education

• Associate’s Degree in nursing, health information management or related healthcare field (Required) And
• Bachelor’s Degree in nursing, health information management or related healthcare field (Preferred) Or

• Master’s Degree in nursing, health information management or related healthcare field (Preferred)

Licenses/Certifications

• CDIP - Clinical Documentation Improvement Professional or CCDS (within 2 years of hire) Upon Hire (Required) And
• RN - Registered Nurse - State Licensure and/or Compact State Licensure in state of practice Upon Hire (Preferred) Or
• RHIA - Registered Health Information Administrator or RHIT Upon Hire (Preferred)

Experience

• 3+ years clinical experience (e.g., inpatient care, documentation review, or case management) (Required) And
• Prior Experience with CDI, ICD-10-CM/PCS, MS-DRGs, and official coding guidelines (Required)