Clinical Document Integrity (CDI) Specialist

Position Requirements

• Active Registered Nurse (RN) license required.
• CSS, CIC, CDIP, and/or CCDS certification preferred, but not required.
• Minimum of three (3) years of recent Clinical Documentation Integrity (CDI) experience in a Level I Trauma Academic Medical Center or Teaching Hospital.
• Recent concurrent inpatient CDI experience required.
• Experience reviewing complex inpatient cases within a Level I Trauma academic healthcare environment required.
• Strong understanding of MS-DRGs, ICD-10-CM/PCS coding guidelines, severity of illness (SOI), risk of mortality (ROM), and compliant physician query practices.
• Experience collaborating directly with physicians and interdisciplinary clinical teams.
• Excellent critical thinking, analytical, and communication skills.
• Experience working within an electronic health record (Epic experience preferred, if applicable).
• Must be authorized to work in the United States.

Key Responsibilities

• Perform concurrent and retrospective reviews of inpatient medical records to improve the quality and accuracy of clinical documentation.
• Identify opportunities to clarify documentation that supports accurate code assignment, severity of illness, risk of mortality, quality metrics, and reimbursement.
• Collaborate with physicians through compliant query practices to obtain complete and accurate documentation.
• Partner with inpatient coding professionals to ensure documentation supports appropriate code assignment and accurate DRG assignment.
• Monitor assigned patient populations throughout hospitalization and perform follow-up documentation reviews as needed.
• Apply current CMS regulations, ICD-10-CM/PCS coding guidelines, MS-DRG methodologies, and Coding Clinic guidance.
• Promote provider education and documentation best practices that improve documentation integrity and patient outcomes.
• Analyze documentation trends and identify opportunities for process improvement.
• Participate in multidisciplinary collaboration to support documentation integrity initiatives.
• Maintain productivity, quality, and compliance standards established by HCCS and our client partners.