PHRN/IP CDI

SENIOR CLINICAL DOCUMENTATION SPECIALIST (CDI)

WHAT YOU'LL DO

• Conduct comprehensive reviews of inpatient medical records

• Identify clinical documentation gaps and opportunities for clarification

• Develop and issue compliant physician queries

• Evaluate clinical indicators, diagnoses, procedures, SOI/ROM and CC/MCC opportunities

• Support accurate ICD-10-CM/PCS and DRG assignment

• Collaborate with physicians, coders, clinical teams and other healthcare stakeholders

• Monitor CDI quality, productivity and query performance metrics

• Provide guidance and mentoring to CDI Specialists

• Participate in audits, quality improvement and CDI program initiatives

• Ensure adherence to AHIMA, ACDIS, CMS and organizational CDI standards

QUALIFICATIONS

Active PHRN license

USRN preferred

Minimum 3-5 years clinical experience, preferably in acute/inpatient care

5 years IP CDI experience

Strong knowledge of ICD-10-CM/PCS, DRGs, CC/MCCs, SOI and ROM

Demonstrated experience with physician queries and documentation clarification

Strong clinical judgment and analytical skills

Excellent written and verbal English communication

Experience with Epic or other major EHR platforms preferred

CDI certification such as CDIP, CCDS, or CIC is highly preferred

US healthcare experience required