Clinical Documentation Integrity Specialist (CDI Specialist)

Job Title: Clinical Documentation Improvement (CDI) Specialist

Job Summary

The Clinical Documentation Improvement (CDI) Specialist is responsible for

reviewing clinical documentation to ensure accuracy, completeness, and compliance

with regulatory and coding requirements. The role focuses on improving the quality

of physician documentation to support accurate coding, reimbursement, severity of

illness (SOI), and risk of mortality (ROM).

Key Responsibilities

Review inpatient and/or outpatient medical records to identify documentation

gaps 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, DRG

assignment, SOI, ROM, and quality metrics

Educate providers on documentation best practices and regulatory

requirements

Track and report CDI metrics such as query response rates, CC/MCC

capture, and case mix index (CMI)

Ensure compliance with CMS, AHIMA, ACDIS, and organizational policies

Participate in audits, reviews, and performance improvement initiatives

Required Qualifications

Registered Nurse (RN), or USRN with a strong clinical background

1+ years of experience in CDI with medical coding, or clinical documentation

review

Strong knowledge of ICD10CM/PCS, DRGs, CC/MCCs, and clinical indicators

Familiarity with quality measures, SOI/ROM, and reimbursement

methodologies

Excellent written and verbal communication skills