Job Description

Clinical Documentation Improvement Specialist

Make your clinical expertise count — beyond the bedside.

We're looking for a CDI Specialist who knows that great patient care starts with great documentation. In this role, you'll partner directly with physicians, nurses, and coders to ensure clinical documentation tells the full story — capturing the true severity of illness, the complexity of care delivered, and the outcomes that matter.

Your work will directly impact reimbursement accuracy, quality scores, and how our hospital's care is reflected to the world.

What You'll Do:

• Review inpatient medical records concurrently and retrospectively to identify documentation gaps and improvement opportunities
• Craft compliant, non-leading physician queries that clarify diagnoses, procedures, and clinical indicators
• Educate and coach providers on documentation best practices and regulatory requirements
• Monitor key metrics including CMI trends, query response rates, HACs, and PSI indicators
• Support denial management with clinical justifications for appealed claims
• Collaborate with coding teams to ensure accurate DRG assignment
• Develop documentation policies aligned with CIHQ accreditation standards

What You Bring:

• Associate or bachelor's degree in Nursing, HIM, or a related healthcare field
• 3+ years of clinical experience in acute care (ER, ICU, med-surg, or case management preferred)
• 2+ years of CDI experience with concurrent review and physician querying
• Active, unencumbered RN license (if nursing background)
• RN, RHIA, RHIT, CCS, CCDS, CDIP, or related certification preferred
• Strong knowledge of CMS, AHIMA, and ACDIS standards
• A collaborative approach and the ability to build trust with medical staff

Bonus Points For:

• CCDS or CDIP certification
• Additional coding credentials (CCS, CPC, CIC)

Why This Role?

This isn't a back-office job — you'll be rounding with physicians, shaping how care is captured, and making a measurable impact on quality and revenue. If you love the intersection of clinical knowledge, data, and education, this is your lane.

Reports to: VP of Revenue Cycle

Job Tags

Similar Jobs