Clinical Documentation Improvement (CDI) Specialist

Description

Job Summary

 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

Qualifications

• 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

Behavioral Standards

• Wears nametag properly; follows dress code policy; answers phone correctly and promptly; meets deadlines; acts ethically and respectfully.
• Maintains professional and courteous communication with staff, providers, and patients.

Communication/Knowledge

• Understands and explains HIM processes clearly; utilizes AIDET principles in all interactions.
• Provides support and education to departments as needed.

Collaboration/Teamwork

• Attends staff meetings; adheres to HIPAA and patient rights policies.
• Participates in safety, emergency, and disaster response procedures.
• Supports a clean, secure, and organized records environment.

Requirements

 Qualifications

• 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
• On-site role