Clinical Documentation Specialist (CDI)

About the role

The Clinical Documentation Integrity (CDI) Specialist is responsible for reviewing inpatient medical records to ensure accurate, complete, and compliant clinical documentation that reflects the severity of illness (SOI), risk of mortality (ROM), quality outcomes, medical necessity, and appropriate reimbursement. The CDI Specialist collaborates with physicians, coding professionals, and other healthcare team members to improve documentation quality and support accurate code assignment and DRG integrity.

Responsibilities

• Perform concurrent and/or retrospective reviews of inpatient medical records for documentation accuracy, completeness, and compliance.
• Maintain an accuracy rate of 98%.
• Identify opportunities for clarification of diagnoses, procedures, present on admission (POA) indicators, severity of illness, risk adjustment, and clinical validation.
• Initiate compliant physician queries to clarify conflicting, incomplete, or nonspecific documentation.
• Collaborate with coding staff to ensure accurate ICD-10-CM/PCS coding and MS-DRG/APR-DRG assignment.
• Monitor documentation trends related to mortality, quality indicators, hospital-acquired conditions (HACs), patient safety indicators (PSIs).
• Conduct clinical validation reviews for diagnoses such as sepsis, respiratory failure, encephalopathy, malnutrition, acute kidney injury, and other high-risk conditions.
• Maintain productivity and quality standards established by Solventum/facility (query rate of 35-40%, review rate of 20-25 cases per day, and an accuracy rate of 98%).
• Participate in multidisciplinary rounds, provider education, and documentation improvement initiatives.
• Absorb and assist with denial prevention by supporting documentation integrity initiatives.
• Stay current with CMS, ICD-10, AHA Coding Clinic, and organizational compliance standards.
• Typically handles inquiries of moderate scope and complexity within customer service areas, such as Account Management, Upselling, Customer Issue Resolution, Customer Inquiry Support, Customer Service Analytics.
• Manage escalated issues.
• Lead projects and perform complex analysis as well as initiatives which maintain and improve customer service levels.
• If a Team Leader role, provide functional work direction to co-workers as assigned.
• Coach and provide input on the employee performance review.
• Guide team on problem solving and resolution.

Requirements

• Valid Registered Nurse license with a bachelor’s degree or higher (completed and verified prior to start) AND seven (7) years of Nursing experience AND five (5) years of experience in the inpatient acute care setting OR
• High School Diploma/GED AND eleven (11) years of experience as an inpatient acute care setting.

Skills and Expertise

• Experience auditing practices, ICD 10, PCS guidelines, quality initiatives, and MS-DRG and APR DRG methodologies.
• Clinical knowledge and application to coding.
• Experience in CCDS, CCS, or CDIP with (7) seven years of clinical documentation/DRG validator.
• Ability to travel up to 25%.
• Knowledge of the Solventum HIS software portfolio (e.g., 360 Encompass).
• Knowledgeable in Solventum HIS software portfolio (360 Encompass).
• Proficient Microsoft Word, Excel and PowerPoint and other Microsoft Office programs and excellent verbal, written, presentation, analytical and organizational skills.

Benefits

Supporting Your Well-being
Solventum offers many programs to help you live your best life – both physically and financially. To ensure competitive pay and benefits, Solventum regularly benchmarks with other companies that are comparable in size and scope. Onboarding Requirement: To improve the onboarding experience, you will have an opportunity to meet with your manager and other new employees as part of the Solventum new employee orientation. As a result, new employees hired for this position will be required to travel to a designated company location for on-site onboarding during their initial days of employment. Travel arrangements and related expenses will be coordinated and paid for by the company in accordance with its travel policy.

Pay

The specific compensation offered to a candidate may vary based on factors including, but not limited to, the candidate’s relevant knowledge, training, skills, work location, and/or experience. In addition, this position may be eligible for a range of benefits (e.g., Medical, Dental & Vision, Health Savings Accounts, Health Care & Dependent Care Flexible Spending Accounts, Disability Benefits, Life Insurance, Voluntary Benefits, Paid Absences and Retirement Benefits, etc.).

Schedule

Remote-United States

Qualifications

• Must be legally authorized to work in country of employment without sponsorship for employment visa status (e.g., H1B status).