CDI Specialist

Position Summary

The CDI Specialist improves the accuracy, clarity, and completeness of clinical documentation across inpatient, same-day surgery, observation, and emergency encounters. This role conducts concurrent medical record reviews, identifies opportunities to strengthen documentation, and works collaboratively with physicians, clinical staff, and HIM coding teams to ensure clinical severity, patient conditions, and services provided are clearly and accurately reflected. The CDI Specialist supports high-quality patient care by promoting documentation practices that align with true clinical acuity, support appropriate coding, and provide reliable data for reporting and outcomes measurement. Through ongoing education, effective communication, and expert clinical analysis, the position plays an important role in strengthening compliance, quality metrics, and overall organizational performance.

Key Responsibilities

• Perform concurrent clinical documentation reviews to evaluate accuracy, completeness, and clinical relevance of diagnoses, procedures, and supporting indicators.
• Collaborate with providers, nursing staff, Clinical Excellence and Patient Safety (CEPS), and HIM coding teams to clarify documentation and ensure severity of illness and risk of mortality are appropriately reflected.
• Initiate and track documentation queries in accordance with organizational guidelines and regulatory expectations.
• Analyze working DRGs/APCs and recommend documentation updates needed for accurate coding, reimbursement, and quality reporting.
• Educate providers and clinical staff on documentation best practices, regulatory requirements, and opportunities for improvement.
• Maintain organized documentation, reporting, and communication workflows to support CDI program goals and performance monitoring.