Clinical Documentation Integrity Specialist (CDI Specialist)

Key Responsibilities:

• Review inpatient and/or outpatient medical records to identify documentationgaps and opportunities for improvement
• Collaborate with physicians, coders, and clinical staff to clarify diagnoses,procedures, and clinical indicators
• Initiate and follow up on physician queries in accordance with compliant query guidelines
• Ensure documentation supports accurate ICD10CM/PCS coding, DRGassignment, SOI, ROM, and quality metrics
• Educate providers on documentation best practices and regulatory requirements
• Track and report CDI metrics such as query response rates

Qualifications

• USRN with a strong clinical background
• 1+ years of experience in CDI with medical coding, or clinical documentation review
• Excellent written and verbal communication skills