Clinical Documentation Improvement (CDI) Specialist

Job Summary

The Clinical Documentation Improvement (CDI) Specialist is responsible for reviewing clinical documentation to ensure accuracy, completeness, and compliance with regulatory and coding requirements. The role focuses on improving the quality of physician documentation to support accurate coding, reimbursement, severity of illness (SOI), and risk of mortality (ROM).

Key Responsibilities

• Review inpatient and/or outpatient medical records to identify documentation gaps and opportunities for improvement
• Collaborate with physicians, coders, and clinical staff to clarify diagnoses, procedures, and clinical indicators
• Initiate and follow up on physician queries in accordance with compliant query guidelines
• Ensure documentation supports accurate ICD10CM/PCS coding, DRG assignment, SOI, ROM, and quality metrics
• Educate providers on documentation best practices and regulatory requirements
• Track and report CDI metrics such as query response rates, CC/MCC capture, and case mix index (CMI)
• Ensure compliance with CMS, AHIMA, ACDIS, and organizational policies
• Participate in audits, reviews, and performance improvement initiatives

Required Qualifications

• Registered Nurse (RN), or USRN with a strong clinical background
• 1+ years of experience in CDI with medical coding, or clinical documentation review
• Strong knowledge of ICD10CM/PCS, DRGs, CC/MCCs, and clinical indicators
• Familiarity with quality measures, SOI/ROM, and reimbursement methodologies
• Excellent written and verbal communication skills