Concurrent Clinical Documentation Integrity (CDI) Specialist
About The Position
This position enhances the quality, accuracy, completeness, and integrity of clinical documentation in the medical record, ensuring that it accurately reflects patients’ severity of illness, risk of mortality, diagnoses, procedures, and services provided. The role conducts high-volume concurrent reviews of inpatient medical records to identify opportunities to improve documentation accuracy, completeness, and specificity. It is part of a specialized production team designed to maximize review capacity through focused clinical review activities. Through comprehensive clinical record review, the specialist identifies documentation opportunities, facilitates compliant clinical documentation clarification, and supports accurate coding, quality reporting, reimbursement, and regulatory compliance. The role contributes to organizational performance related to quality outcomes, case mix index, and reimbursement. It requires consistent performance in a high-production environment while meeting established productivity goals and maintaining a minimum quality review score of 95% through departmental audits and performance evaluations. The position does not include physician query follow-up or outreach, query escalation or reconciliation, or CDI/Coding reconciliation; these functions are handled by dedicated teams. The role is remote and scheduled for 40 hours per week, Monday through Friday.
Requirements
- Associate’s degree in a related healthcare field, such as medical coding and billing, nursing, or healthcare administration.
- One year of Clinical Documentation Integrity (CDI) experience in an acute care setting; or one year of acute care clinical experience in ICU, Emergency Department, Critical Care, or Medical-Surgical specialties, case management, utilization review, or denials management.
- Active, unrestricted Registered Nurse (RN) license in Massachusetts or an NLC state; or AHIMA Certified Coding Specialist (CCS) credential; or AAPC Certified Inpatient Coder (CIC) credential.
- Ability to read and write English and communicate fluently enough to be understood by patients, hospital personnel, physicians, and visitors.
- Strong critical thinking skills and a sound clinical background, including working knowledge of disease processes, anatomy and physiology, and treatment regimens.
- Ability to analyze and interpret clinical information in patient medical records.
- Excellent verbal and written communication skills, with strong attention to detail and accuracy.
- Knowledge of ICD-10, AHIMA and coding guidelines, healthcare regulations, reimbursement, and documentation requirements.
- Ability to be open, flexible, and adaptable in a changing environment.
- High level of computer literacy and technology efficiency, including Microsoft Office Suite (Word, Excel, and Teams), Zoom, Epic, and 3M360.
- Ability to use good judgment in an emergency situation.
Nice To Haves
- Bachelor’s degree in nursing (BSN) or Registered Health Information Administrator (RHIA) credential.
- Two years of Clinical Documentation Integrity (CDI) experience in an acute care setting.
- Certified Clinical Documentation Specialist (CCDS) and/or Clinical Documentation Improvement Practitioner (CDIP) certification.
Responsibilities
- Perform initial and subsequent concurrent reviews of electronic medical records to identify documentation opportunities while meeting concurrent review volume goals and quality and accuracy standards.
- Evaluate medical records for completeness, consistency, precision, and clarity.
- Identify opportunities for provider clarification and record and issue compliant, clinically supported queries in accordance with organizational policies and industry guidelines.
- Use professional judgment to determine when provider queries are warranted and when existing documentation sufficiently supports accurate code assignment, avoiding unnecessary or non-compliant queries.
- Maintain alignment with coding professionals and stay current with coding guidelines.
- Accurately document reviews and other pertinent information in designated systems in compliance with policies, procedures, and documentation standards.
- Apply critical thinking and medical knowledge of disease processes to integrate clinical information.
- Manage time and prioritize work efficiently to achieve key operating metrics consistent with CDI Department needs and requirements.
- Proactively address problems, resolve conflicts, and troubleshoot technology errors.
Benefits
- Comprehensive Total Rewards package supporting health, financial security, and career growth.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
