This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Clinical Documentation Improvement Specialist based in the United States.
As a Clinical Documentation Improvement (CDI) Specialist, you will play a vital role in enhancing the accuracy, completeness, and quality of clinical documentation across inpatient healthcare settings. Working closely with physicians, coders, and multidisciplinary teams, you will help ensure medical records accurately reflect patient severity, complexity of care, and clinical outcomes. This position combines clinical expertise with documentation and coding knowledge to support compliance, reimbursement accuracy, and quality reporting initiatives. You will contribute to process improvements, provide education to healthcare professionals, and participate in specialized reviews focused on patient safety and quality metrics. The role offers a dynamic environment where continuous learning, collaboration, and critical thinking are highly valued. It is an excellent opportunity for experienced nursing professionals seeking to make a meaningful impact on healthcare quality and operational performance.
Accountabilities
- Conduct concurrent and retrospective reviews of inpatient medical records to identify opportunities for documentation improvement and coding accuracy.
- Initiate physician queries and collaborate with providers to clarify ambiguous, incomplete, or conflicting documentation to support accurate coding and clinical representation.
- Facilitate documentation that appropriately reflects severity of illness, risk of mortality, complexity of care, case mix index (CMI), length of stay (LOS), and resource utilization.
- Educate physicians, clinical staff, and stakeholders on documentation standards, coding guidelines, reimbursement requirements, and regulatory expectations.
- Apply coding principles, reimbursement guidelines, and documentation standards to support accurate working DRG assignments and clinical documentation integrity.
- Collaborate with coding teams, auditors, quality improvement professionals, and other stakeholders to resolve documentation issues and improve data quality.
- Conduct focused reviews related to mortality, patient safety indicators (PSIs), and other quality or compliance initiatives identified by leadership.
- Monitor evolving documentation, coding, and regulatory requirements to ensure ongoing compliance and best practices.
- Assist with onboarding, training, and mentoring new CDI team members.
- Contribute to continuous improvement initiatives aimed at enhancing documentation quality, reporting accuracy, and operational effectiveness.
Requirements
- Associate Degree in Nursing required; Bachelor of Science in Nursing (BSN) preferred.
- Active and unrestricted U.S. Registered Nurse (RN) license required.
- Three to five years of recent clinical experience in medical-surgical, intensive care, telemetry, emergency department, or related acute care settings.
- Strong knowledge of clinical documentation improvement practices, coding methodologies, reimbursement structures, and healthcare quality measures.
- Experience working with electronic medical record (EMR) systems and CDI technology platforms.
- Understanding of CMS regulations, coding guidelines, compliance standards, and healthcare documentation requirements.
- Excellent critical thinking, analytical, and problem-solving skills with the ability to evaluate complex clinical scenarios.
- Strong written and verbal communication skills with the ability to effectively educate providers and clinical teams.
- Ability to work independently, manage multiple priorities, and thrive in a fast-paced healthcare environment.
- Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
- Strong interpersonal skills, professional judgment, adaptability, and commitment to continuous learning.
Benefits
- Competitive annual salary ranging from $48,131 to $81,225.49, based on experience, qualifications, location, and job-related skills.
- Eligibility for an annual performance bonus with a target incentive opportunity.
- Comprehensive healthcare and wellness benefits.
- Retirement savings and financial wellbeing programs.
- Paid time off and company-recognized holidays.
- Professional development, ongoing education, and career advancement opportunities.
- Collaborative and supportive work environment focused on innovation and continuous improvement.
- Opportunity to contribute to meaningful healthcare initiatives that positively impact patient outcomes and organizational performance.
- Exposure to cross-functional teams and evolving healthcare technologies and processes.