CDI Specialist

Job Summary

The Clinical Documentation Integrity (CDI) Specialist at Palestine Regional Medical Center is responsible for improving the quality, accuracy, and completeness of clinical documentation in the medical record. This role involves collaborating with physicians, nurses, coders, and other healthcare team members to ensure that documentation accurately reflects the severity of illness, risk of mortality, and complexity of care. The CDI Specialist supports compliance, quality initiatives, and reimbursement through accurate coding and reporting.

Essential Functions

• Perform concurrent reviews of inpatient records to identify opportunities for clarification, specificity, and documentation completeness.
• Initiate and follow up on provider queries in accordance with official coding and organizational standards.
• Abstract clinical data to support coding and DRG accuracy.
• Educate physicians and clinical staff on documentation best practices and regulatory requirements.
• Review documentation for Present on Admission (POA), Hospital-Acquired Conditions (HACs), and other quality indicators.
• Collaborate with case management, quality, compliance, and HIM teams to support clinical accuracy and financial integrity.
• Analyze and report trends related to documentation improvement opportunities and query response rates.
• Maintain current knowledge of CMS regulations, IPPS, AHA Coding Clinics, and industry guidelines.
• Aid with documentation audits and performance improvement initiatives.
• Present educational sessions to providers and staff on clinical documentation topics.
• Uphold ethical, legal, and regulatory standards related to patient privacy and coding practices.

Knowledge/Skills/Abilities/Expectations

• In-depth understanding of clinical care delivery, coding systems (ICD-10, MS-DRG), and documentation regulations.
• Excellent written and verbal communication skills.
• Ability to engage physicians and interdisciplinary teams in a collaborative, educational manner.
• Proficient in EMR systems and data analytics tools.
• Strong attention to detail, organizational skills, and independent judgment.
• Ability to manage multiple tasks and meet documentation timelines.

Qualifications

• Education: Associate’s Degree in nursing, health information management, or related healthcare field (Required); Bachelor’s Degree in nursing, health information management, or related healthcare field (Preferred); Master’s Degree in nursing, health information management, or related healthcare field (Preferred).
• Licenses/Certifications: CDIP - Clinical Documentation Improvement Professional or CCDS (within 2 years of hire) upon hire; RN - Registered Nurse - State Licensure and/or Compact State Licensure in state of practice upon hire (Preferred); RHIA - Registered Health Information Administrator or RHIT upon hire (Preferred).
• Experience: 3+ years clinical experience (e.g., inpatient care, documentation review, or case management) (Required); Prior Experience with CDI, ICD-10-CM/PCS, MS-DRGs, and official coding guidelines (Required).