Offer summary

Qualifications:

Bachelor's degree in Nursing, Health Information Management, or a related healthcare field preferred., Minimum of 3 years of experience in Clinical Documentation Integrity, Health Information Management, or coding., Certifications such as CCDS, CDIP, RHIA, or RHIT are required or preferred., Strong knowledge of ICD-10-CM/PCS coding and familiarity with CDI software and EHR systems..

Key responsabilities:

Conduct reviews of medical records to ensure accuracy and completeness of clinical documentation.

Collaborate with healthcare professionals to clarify documentation issues.

Utilize CDI software to track and report on documentation trends.

Provide education on best practices for clinical documentation integrity.

Job description

CDI Specialist

Job Summary
The CDI Specialist will work collaboratively with healthcare providers, coding professionals, and revenue cycle teams to improve clinical documentation accuracy, ensure compliance with coding and regulatory standards, and enhance the quality of patient records. This is a remote position, available to candidates within the United States.

Key Responsibilities

Conduct concurrent and retrospective reviews of inpatient and outpatient medical records to ensure accuracy, completeness, and specificity of clinical documentation.
Collaborate with physicians, advanced practice providers, and other healthcare professionals to clarify ambiguous, incomplete, or conflicting documentation.
Utilize CDI software and electronic health records (EHR) to track, analyze, and report on documentation trends and improvement opportunities.
Work closely with coding professionals to ensure appropriate code assignment and reimbursement compliance.
Provide education and training to healthcare providers and internal teams on best practices for clinical documentation integrity and regulatory compliance.
Stay current on evolving CDI standards, ICD-10-CM/PCS guidelines, DRG methodologies, CMS regulations, and industry best practices.
Participate in ongoing audits, quality improvement initiatives, and performance monitoring to support organizational goals.
Maintain compliance with HIPAA and other regulatory requirements related to medical documentation and patient privacy.

Qualifications & Requirements

Education: Bachelor's degree in Nursing (BSN), Health Information Management (HIM), or a related healthcare field preferred. Equivalent work experience may be considered.
Minimum of 3 years of experience in Clinical Documentation Integrity (CDI), Health Information Management (HIM), or inpatient/outpatient coding.
Certifications: One or more of the following certifications required:
Certified Clinical Documentation Specialist (CCDS) – ACDIS
Certified Documentation Improvement Practitioner (CDIP) – AHIMA
Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) preferred
Strong knowledge of ICD-10-CM/PCS coding, MS-DRG, APR-DRG, and severity of illness (SOI)/risk of mortality (ROM) methodologies.
Familiarity with CDI software, EHR systems (Epic, Cerner, Meditech, etc.), and healthcare reimbursement methodologies.

Skills & Competencies:

Excellent analytical, communication, and problem-solving skills.
Ability to engage and educate physicians and healthcare staff effectively.
Strong attention to detail and ability to work independently in a remote setting.
Proficiency in Microsoft Office Suite and CDI-related reporting tools.

Preferred Qualifications