Clinical Documentation Integrity (CDI) Specialist

Accountabilities:

• Conduct comprehensive initial and follow-up concurrent reviews of inpatient medical records according to established CDI priorities, timelines, and review frequencies.
• Identify incomplete, conflicting, or clinically unclear documentation and determine appropriate opportunities for clarification or diagnosis validation.
• Apply clinical validation principles and current ACDIS/AHIMA compliant query guidelines when preparing written queries for treating physicians.
• Develop compliant queries using approved templates and ensure that relevant, patient-specific clinical indicators are accurately documented.
• Identify principal and secondary diagnoses and significant procedures to establish and update the appropriate working MS-DRG.
• Monitor documentation throughout concurrent reviews and update working DRGs and expected length-of-stay considerations as appropriate.
• Apply knowledge of Patient Safety Indicators, Hospital-Acquired Conditions, Severity of Illness, Risk of Mortality, and present-on-admission status.
• Track physician responses to queries and ensure all relevant outcomes and documentation are accurately captured in the appropriate systems.
• Maintain productivity and quality benchmarks while effectively managing daily CDI worklists and priorities.
• Enter required information into CDI applications and related systems to support final MS-DRG, SOI, and ROM determinations.
• Use electronic coding references, Official Coding Guidelines, and Coding Clinic resources to support accurate coding and working DRG assignments.
• Collaborate with coding teams on ICD-10 coding questions, MS-DRG assignments, concurrent and retrospective queries, and DRG reconciliation.
• Participate in DRG reconciliation activities in a timely, thorough, and collaborative manner.
• Contribute to departmental committees, hospital task forces, service-line meetings, and other assigned initiatives.
• Promote a positive, collaborative working environment while maintaining compliance with HIPAA requirements and applicable codes of conduct.

Requirements

• Bachelor’s degree preferred; relevant professional experience or an advanced degree may substitute for formal education.
• Current and active credentials as an RN, MD or equivalent, RHIA, RHIT, or CCS.
• At least 2 years of acute-care inpatient hospital coding or CDI experience.
• Familiarity with encoder systems and MS-DRG assignment.
• Current working knowledge of official coding guidelines and Coding Clinic resources.
• Strong clinical understanding of disease processes and the ability to apply clinical indicators appropriately to documentation reviews.
• Strong knowledge of medical terminology, anatomy, physiology, microbiology, and related clinical concepts.
• Demonstrated critical-thinking, analytical, and problem-solving abilities.
• Experience working with EHR systems, CDI software, coding applications, and electronic encoders.
• Strong typing, computer, documentation, and data-entry skills.
• Excellent written and verbal communication skills, with the ability to communicate tactfully and effectively with physicians and other healthcare professionals.
• Confidence navigating potentially difficult or sensitive conversations with physicians while maintaining professionalism and compliance.
• Strong organizational skills and attention to detail, with the ability to manage multiple reviews, queries, deadlines, and documentation requirements.
• Ability to work independently while collaborating effectively with coding, clinical, and operational teams.
• CCDS or CDIP certification is preferred.

Benefits

• Annual salary range of $68,000–$113,000 USD.
• Compensation may vary based on skills, experience, training, licensure, certifications, and other organizational factors.
• Medical, prescription, dental, and vision insurance.
• Personal and family sick time.
• Company-paid holidays.
• Potential eligibility for a discretionary variable incentive bonus.
• Parental leave.
• 401(k) retirement plan.
• Basic and supplemental life insurance.
• Health Savings Account and Flexible Spending Accounts for healthcare and dependent care.
• Short-term and long-term disability coverage.
• Tuition reimbursement.
• Personal development and learning opportunities.
• Skills development and certification support.
• Employee referral program.
• Corporate-sponsored events and community outreach opportunities.
• Emergency backup childcare program.
• Fully remote position within the United States.
• No travel required.