Clinical Documentation Integrity Specialist – FT
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Job Description
CDI Specialist performing concurrent inpatient documentation reviews to enhance documentation accuracy for healthcare organizations. Collaborating with teams to support coding accuracy and compliance standards.
Responsibilities:
- Perform concurrent inpatient documentation reviews to identify opportunities for improved documentation specificity, clinical validation, and coding accuracy.
- Conduct compliant physician queries following AHIMA/ACDIS guidance to clarify conflicting, incomplete, or ambiguous documentation.
- Support accurate ICD-10-CM/PCS coding, MS-DRG/APR-DRG assignment, POA indicators, CC/MCC capture, SOI/ROM, PSIs, HACs, and quality metrics.
- Perform clinical validation reviews for high-impact diagnoses including sepsis, acute respiratory failure, AKI, encephalopathy, malnutrition, and other complex conditions.
- Collaborate with coding, CDI, quality, and physician teams to improve documentation quality and reduce denials.
- Provide physician and CDI education based on documentation trends and audit findings.
- Monitor productivity, quality, and compliance standards while participating in internal audits and continuous improvement initiatives.
- Maintain current knowledge of CMS regulations, ICD-10-CM/PCS, Coding Clinic, AHIMA, and ACDIS guidance.
Requirements:
- Active RN license or graduate of an accredited medical program (MD, DO, MBBS, NP, PA, or equivalent clinical background)
- CCDS or CDIP certification required
- Minimum 5 years of concurrent inpatient CDI experience in an acute care hospital
- Strong knowledge of MS and APR-DRG reimbursement, ICD-10-CM/PCS, clinical validation, and compliant query practices
- Experience with Epic, Cerner, Solventum 360, Iodine, SmarterDx, or similar CDI platforms
Benefits:
- medical/dental/vision benefits first of the month following date of hire
- 401k benefits plus paid holidays and PTO/personal time
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