Clinical Documentation Integrity Specialist - Clinical Doc Integrity - Full-Time

Woman's Hospital • Baton Rouge, LA

11d • $63,000 - $91,000 • Hybrid

About The Position

The Clinical Documentation Integrity (CDI) Specialist is responsible for reviewing clinical documentation to ensure it accurately, completely, and consistently reflects the patient’s clinical condition, severity of illness (SOI), risk of mortality (ROM), and care provided. The role supports compliant documentation practices in accordance with ACDIS and AHIMA-endorsed guidelines, official coding rules, and applicable regulatory requirements. The CDI Specialist serves as a clinical documentation resource to providers, coding professionals, quality teams, and revenue cycle stakeholders, promoting high-quality healthcare data for reimbursement, quality reporting, compliance, and population health analysis.

Requirements

• Two-year associate degree or four-year bachelor’s degree in nursing.
• Applicable clinical license such as RN or LPN.
• Five years clinical work experience in an acute care setting.

Nice To Haves

• Professional CDI certification, CCDS or CDIP, preferred or obtained within 3 years of hire.
• Professional coding certification, CCS, preferred or obtained within 2 years of obtaining CDI credential or upon hire.
• Experience in Clinical Documentation Integrity, Coding, Health Information Management, Quality, Utilization/Case Management, Chart Review, Auditing, Denials Management, or related field including practical exposure to the healthcare revenue cycle preferred.

Responsibilities

• Conduct concurrent and retrospective reviews of inpatient medical records to identify documentation gaps, inconsistencies, and opportunities for improvement.
• Analyze clinical indicators, diagnostics, and treatment plans to ensure documentation supports diagnoses and procedures.
• Ensure documentation accurately reflects patient acuity, severity of illness (SOI), and risk of mortality (ROM).
• Initiate and follow up on compliant physician queries to clarify documentation in accordance with industry guidelines.
• Educate physicians and clinical staff on documentation best practices, regulatory requirements, and specificity.
• Collaborate with coding teams to ensure accurate code assignment, including MS-DRGs, CC/MCC capture, and reimbursement alignment.
• Identify documentation opportunities impacting case mix index (CMI), quality metrics, and reimbursement.
• Review documentation for alignment with medical necessity, admission status, and level-of-care requirements.
• Support quality reporting initiatives, including patient safety indicators and risk-adjusted performance metrics.
• Track CDI activities and participate in audits, performance improvement initiatives, and ongoing program development.
• Any other duties as assigned by Woman's Hospital.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees