Clinical Documentation Improvement (CDI) Specialist
About The Position
The CDI Specialist works collaboratively with providers and clinical teams to ensure accurate, complete, and compliant clinical documentation that reflects patient acuity, severity of illness, and quality of care.Key Responsibilities Review inpatient and/or outpatient medical records for documentation accuracy and completeness Identify documentation gaps and initiate provider queries when appropriate Ensure documentation supports correct coding, billing, and quality reporting Collaborate with providers, coders, and clinical staff to improve documentation practices Educate providers on documentation standards, guidelines, and best practices Monitor compliance with regulatory and payer requirements
Requirements
- Clinical background (RN preferred; LPN, RHIA, RHIT, CCS, CCDS, or CDIP considered)
- Strong knowledge of ICD-10-CM/PCS, MS-DRG/APR-DRG methodologies
- Experience with clinical documentation review and provider querying
- Strong communication and analytical skills
Responsibilities
- Review inpatient and/or outpatient medical records for documentation accuracy and completeness
- Identify documentation gaps and initiate provider queries when appropriate
- Ensure documentation supports correct coding, billing, and quality reporting
- Collaborate with providers, coders, and clinical staff to improve documentation practices
- Educate providers on documentation standards, guidelines, and best practices
- Monitor compliance with regulatory and payer requirements
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
