CDI Specialist

Community Medical Group•Corporate, Miami, FL, US, FL

About The Position

The CDI Specialist plays a critical role in enhancing the accuracy and completeness of clinical documentation within healthcare settings. This position focuses on reviewing patient records to ensure that all diagnoses, treatments, and procedures are thoroughly and precisely documented to support quality patient care and appropriate reimbursement. The specialist collaborates closely with physicians, nurses, and coding professionals to clarify documentation and resolve discrepancies. By improving documentation practices, the CDI Specialist helps healthcare organizations meet regulatory requirements and optimize clinical data integrity. Ultimately, this role contributes to better patient outcomes, accurate reporting, and efficient healthcare operations.

Requirements

Bachelor’s degree in Nursing, Health Information Management, or a related healthcare field.
Certified Clinical Documentation Specialist (CCDS) credential or equivalent certification.
Minimum of 2 years experience in clinical documentation improvement or health information management.
Strong knowledge of medical terminology, anatomy, and clinical procedures.
Familiarity with ICD-10-CM, CPT coding systems, and healthcare reimbursement methodologies.
Strong analytical skills are used daily to review complex medical records and ensure compliance with coding standards.
Effective communication skills facilitate productive interactions with physicians and clinical staff to clarify documentation and promote best practices.
Familiarity with EHR systems and coding software supports efficient documentation review and data management.

Nice To Haves

Experience working in a hospital or acute care setting.
Additional certifications such as Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).
Proficiency with electronic health record (EHR) systems and clinical documentation software.
Demonstrated ability to lead documentation improvement projects.
Excellent communication and interpersonal skills for effective collaboration with multidisciplinary teams.

Responsibilities

Review clinical documentation in patient records to identify gaps or inconsistencies.
Engage with healthcare providers to clarify and obtain additional information as needed.
Ensure documentation supports accurate coding and billing processes.
Collaborate with coding and billing teams to facilitate proper claim submissions.
Monitor and report on documentation improvement initiatives and compliance with regulatory standards.
Provide education and training to clinical staff on documentation best practices.
Stay current with industry regulations, coding guidelines, and documentation standards.