Clinical Documentation Improvement (CDI) Specialist/Medical Coder

Description

Are you passionate about accuracy, compliance, and the integrity of the medical record? Northwest Mississippi Regional Medical Center (NWMRMC) is seeking a detail-oriented Clinical Documentation Improvement (CDI) Specialist/Medical Coder to join our healthcare team.

In this critical role, you will support high-quality patient care, regulatory compliance, and financial integrity by ensuring clinical documentation is complete, accurate, and reflective of the patient’s severity of illness and services provided. Your work will directly impact quality outcomes, coding accuracy, and appropriate reimbursement.

About Us: 

At Northwest Mississippi Regional Medical Center, we are committed to providing high quality, sustainable healthcare to the citizens of Northwest Mississippi. We believe in a collaborative work environment where each team member plays an integral role in promoting the health and well-being of our patients.

Why Join Us?

• Mission-Driven Work: Support a community-focused healthcare organization dedicated to improving lives.
• Professional Growth: Opportunities for training, development, and career advancement.
• Comprehensive Benefits: Competitive salary, health insurance, retirement plan, and more.
• Positive Work Environment: Join a team of passionate professionals in a supportive setting.

Requirements

Key Responsibilities:

Clinical Documentation Improvement (CDI)

• Perform concurrent and retrospective reviews of inpatient and outpatient medical records to identify documentation gaps. 
• Query providers to clarify diagnoses, procedures, and clinical indicators in accordance with AHIMA/ACDIS compliant query practices. 
• Ensure documentation supports accurate MS-DRG/APR-DRG assignment, SOI/ROM, HCCs, and quality measures.
• Collaborate with physicians, nursing, case management, and quality teams to improve documentation accuracy and completeness.
• Provide ongoing education to providers on documentation best practices, clinical specificity, and regulatory requirements.
• Track and report CDI metrics, including query response rates, case mix index (CMI), denial trends, and documentation improvement outcomes. 

Medical Coding

• Assign accurate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes for inpatient and outpatient encounters.
• Ensure coding is compliant with CMS, OIG, NCCI, and payer-specific guidelines. 
• Validate principal diagnosis, secondary diagnoses, and procedures to ensure appropriate DRG/APR-DRG assignment.
• Support audits, denials, and appeals by providing coding and documentation expertise.
• Identify and correct coding errors prior to billing to reduce claim denials and rework.

Compliance & Quality Support

• Maintain compliance with federal and state regulations, coding guidelines, and internal policies.
• Support external audits (Medicare, Medicaid, commercial payers) and internal quality initiatives.
• Assist with RAC, MAC, and payer audits as needed. 
• Stay current with changes in coding rules, CDI standards, and reimbursement methodologies. 
• Other duties as assigned. 

Qualifications:

Education: Associate's or Bachelor's Degree in Health Information Management, Nursing, or related field (preferred).  

Experience: 

• Minimum 2-3 years of experience in CDI, inpatient coding, or hospital-based coding.
• Strong knowledge of: ICD-10-CM/PCS Coding, MS-DRG methodology, and CMS and payer documentation and coding guidelines. 
• One or more of the following credentials: RHIT or RHIA, CCS or CCS-P, and CCDS or CDIP.
• Proficiency with electronic health records (EHR) and encoder systems. 

What We Offer:

• Competitive salary and benefits package
• Health, Dental, and Vision Insurance
• Company Paid Basic Life/AD&D Insurance & Long-Term Disability Insurance
• Retirement plan options
• Generous personal time off (PTO) pay schedule
• Supportive, friendly work environment with opportunities for professional development and growth
• The opportunity to make a real impact in the lives of our patients

Be a Part of Something Bigger!

At NWMRMC, we believe in our mission to drive meaningful change in the communities we serve. If you're ready to apply your expertise in a role that truly makes a difference, don't wait-take the next step in your career today. We can't wait to welcome you to our team!

Northwest Mississippi Regional Medical Center (NWMRMC) is an Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity or expression, pregnancy, age, national origin, disability status, genetic information, protected veteran status, or any other characteristic protected by law.