Clinical Documentation Improvement (CDI) Specialist

Exceptional Healthcare Inc. • Dallas, TX

1d

About The Position

Make your clinical expertise count — beyond the bedside. We're looking for a CDI Specialist who knows that great patient care starts with great documentation. In this role, you'll partner directly with physicians, nurses, and coders to ensure clinical documentation tells the full story — capturing the true severity of illness, the complexity of care delivered, and the outcomes that matter. Your work will directly impact reimbursement accuracy, quality scores, and how our hospital's care is reflected to the world. If you love the intersection of clinical knowledge, data, and education, this is your lane.

Requirements

• Associate or bachelor's degree in Nursing, HIM, or a related healthcare field
• 3+ years of clinical experience in acute care (ER, ICU, med-surg, or case management preferred)
• 2+ years of CDI experience with concurrent review and physician querying
• Active, unencumbered RN license (if nursing background)
• Strong knowledge of CMS, AHIMA, and ACDIS standards
• A collaborative approach and the ability to build trust with medical staff

Nice To Haves

• RN, RHIA, RHIT, CCS, CCDS, CDIP, or related certification preferred
• CCDS or CDIP certification
• Additional coding credentials (CCS, CPC, CIC)

Responsibilities

• Review inpatient medical records concurrently and retrospectively to identify documentation gaps and improvement opportunities
• Craft compliant, non-leading physician queries that clarify diagnoses, procedures, and clinical indicators
• Educate and coach providers on documentation best practices and regulatory requirements
• Monitor key metrics including CMI trends, query response rates, HACs, and PSI indicators
• Support denial management with clinical justifications for appealed claims
• Collaborate with coding teams to ensure accurate DRG assignment
• Develop documentation policies aligned with CIHQ accreditation standards

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level