CDI Specialist

Job Summary: The Clinical Documentation Improvement (CDI) Specialist plays a critical role in ensuring the accuracy, completeness, and quality of medical records and clinical documentation to support patient care, coding, compliance, and reimbursement processes. This professional collaborates with physicians, healthcare staff, and coders to clarify documentation and ensure alignment with regulatory and organizational standards.

Key Responsibilities:

• Documentation Review: Analyze medical records to ensure clinical documentation accurately reflects patient diagnoses, procedures, and severity of illness.
• Provider Collaboration: Work closely with physicians and clinical staff to clarify ambiguous, conflicting, or incomplete documentation through queries and educational feedback.
• Compliance Assurance: Ensure documentation complies with healthcare regulations, coding guidelines, and organizational standards.
• Education & Training: Provide education to physicians, clinical staff, and coders regarding best practices in clinical documentation, coding changes, and regulatory requirements.
• Data Reporting: Generate and analyze reports related to documentation accuracy, query response rates, and clinical outcomes to support continuous improvement initiatives.
• Coding Support: Assist coding staff by providing clarifications on clinical terms and documentation issues to ensure accurate and compliant coding.
• Auditing: Conduct periodic audits of medical records to identify areas for improvement and track progress over time.

Qualifications:

• Bachelors degree in Nursing or a related field.
• Active AHIMA or AAPC certification is required.
• At least 1-2 years of experience in clinical documentation improvement, medical coding, or a related healthcare field.
• In-depth knowledge of ICD-10-CM/PCS coding, MS-DRG, and APR-DRG systems.
• Strong understanding of healthcare regulations and compliance requirements, including Medicare and Medicaid guidelines.
• Excellent communication, collaboration, and analytical skills.
• Proficiency with CDI and EMR software tools.

Preferred Skills:

• Experience with query management systems.
• Familiarity with quality metrics and reporting requirements (e.g., HCC coding, quality measures).
• Advanced certification, such as CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner), is a plus.
• This role is pivotal to improving the quality of patient care and ensuring the integrity of healthcare data.

If you have a passion for detail and collaboration in a clinical setting, join our team as a CDI Specialist!