HIS - CDI Specialist - 40 hrs/wk.

About the Role

The Clinical Document Integrity (CDI) Specialist improves the quality of provider documentation to ensure accurate coded data that reflects the patient’s episode of care and intensity of service. The role ensures data integrity, supports accurate reimbursement, and influences provider and hospital profiling through quality reporting.

Responsibilities

• Analyze clinical documentation in inpatient and/or outpatient settings to identify opportunities for improvement impacting coding, quality reporting, and reimbursement. Provide recommendations for identified risks.
• Educate healthcare providers on the importance of accurate and complete documentation, including presentations to medical staff committees, individual education, and written communication (e.g., letters, newsletters).
• Perform concurrent reviews of inpatient medical records to identify documentation improvement opportunities related to coding and quality initiatives. Interact with providers through written queries or verbal communication as needed.
• Support the HIS Coding team on retrospective query processes and facilitate provider resolution.
• Partner with the HIS coding team to ensure accuracy of diagnostic and procedural data, completeness of documentation, and appropriate DRG, severity of illness, and risk of mortality determination.
• Participate in third-party payer audits, defend clinically focused take-backs, and assist in the appeal process. Support resolution of identified issues and document decisions in policies or procedures.
• Collaborate with HIS coding teams and other key areas to ensure an accurate and compliant representation of clinical care for coding and reimbursement.
• Analyze and trend statistical data from internal practices and industry resources (e.g., PEPPER reports, Integrity Audit issues, RAC, OIG, Healthgrades) to identify documentation improvement opportunities and recommend solutions.
• Support organizational initiatives dependent on clinical documentation quality, including chart reviews, education, Performance Improvement events, and participation in committees or task forces.

Requirements

• Associate’s degree in a related field (e.g., nursing or clinical professions) or 4+ years of comparable experience.
• Registered Nurse (RN), Registered Health Information Administrator (RHIA), or other clinical certification/licensure.
• Certification in CDI (CCDS or CDIP) required; if not certified at hire, must achieve within 24 months.
• Proficient knowledge of ICD-10/DRG, CPT/APC classification systems, IPPS and OPPS reimbursement methodologies, and regulatory compliance.
• Ability to compile, analyze, and present complex data effectively to diverse audiences, including medical providers and leadership.
• Advanced technical aptitude with proficiency in MS Office Suite, electronic health records, and healthcare applications (e.g., 3M Encoder).
• Strong interpersonal and communication skills to interact with physicians, case managers, coders, and clinical departments.
• Valid driver’s license (Ohio license required within 30 days of residency) and compliance with company fleet policy and insurance requirements.
• Effective written communication, presentation, and computer skills.
• Strong organizational, prioritization, and analytical skills.

Preferred Qualifications

• Bachelor’s degree (BSN preferred).
• Previous CDI experience.
• CCS/CCA credentials.

Physical Demands

• Full range of body motion, including intermittent bending, squatting, kneeling, and twisting.
• Ability to sit for 3 hours, walk for 1 hour, and stand for 2 hours per day.
• Must be able to lift 20 pounds.
• Excellent eye/hand coordination for operating machines.
• Corrected vision and hearing within normal range.