CDI Specialist (RN) - Onsite
About The Position
The Clinical Documentation Integrity (CDI) Specialist improves the 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 Specialist ensures documentation reflects the patient’s severity of illness, risk of mortality, and complexity of care. The role supports compliance, quality initiatives, and reimbursement through accurate coding and reporting. The Specialist reviews inpatient records, identifies documentation opportunities, initiates provider queries, abstracts clinical data, educates clinical staff, and collaborates across departments. The position also monitors quality indicators and documentation trends, supports audits and performance improvement initiatives, and maintains knowledge of applicable regulations and industry guidelines.
Requirements
- Associate’s degree in nursing, health information management, or a related healthcare field.
- CDIP (Clinical Documentation Improvement Professional) or CCDS certification within 2 years of hire.
- At least 3 years of clinical experience, such as inpatient care, documentation review, or case management.
- Prior experience with CDI, ICD-10-CM/PCS, MS-DRGs, and official coding guidelines.
- 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.
- Proficiency 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.
Nice To Haves
- Bachelor’s or master’s degree in nursing, health information management, or a related healthcare field.
- RN state licensure and/or compact state licensure in the state of practice.
- RHIA (Registered Health Information Administrator) or RHIT credential.
Responsibilities
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
