CDI Specialist
CDI Specialist
Posted on :
08-04-2025
Employer Active
1 Vacancy
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Monthly Salary
Not Disclosed
Salary Not Disclosed
Vacancy
1 Vacancy
Posted on :
08-04-2025
Job Description
Job: CDI Specialist
Classification: Salaried/Exempt
FLSA Category: Administrative Exemption
Job Category: 2 Professionals
Position Summary
Working independently the Clinical Documentation Integrity (CDI) Specialist performs/ initial/ concurrent/retrospective reviews of the health record to ensure the capture of complete and accurate provider documentation. As appropriate generates and issues compliant queries to clarify documentation that is incomplete conflicting or ambiguous. Initiates contact with physicians to obtain complete and timely query responses. Educates care providers on documentation best practices. This includes but is not limited to capturing the clinical picture of a patient through complete and accurate documentation for correct code/DRG assignment accurate quality measure reporting appropriate reimbursement and accurate risk adjusted scores.
The Clinical Documentation Integrity (CDI) Specialist carries out the operational performance of the defined Clinical Documentation Integrity (CDI) program.
Essential Functions
Conducts initial and extendedstay concurrent reviews on selected admissions consistent with program/department volume and frequency requirements. Documents and reviews other pertinent information in designated systems.
Analyzes documented and clinically supported conditions in the health record to ensure the capture of accurate and completion documentation resulting in final code/DRG assignment with the highest degree of specificity and accuracy.
Demonstrates knowledge of the ICD10CM/PCS Official Guidelines for Coding and Reporting and the DRG classification systems to ensure compliance with regulatory requirements related to CDI and coding functions.
Using critical thinking skills and clinical judgement determines when and/or if a provider query is necessary in accordance with the ACDISAHIMA Practice Brief titled Guidelines for Achieving a Compliant Query Practice.
Uses clinical judgement to determine appropriate and relevant clinical indicators and/or reasonable diagnostic options to formulate patient specific queries per Query Policy.
Physician queries are generated to assist and improve the quality of the documentation.
Collaborates with coding professionals to support clinical code/DRG assignment and resolve identified discrepancies.
Develops collaborative relationships and possesses excellent interpersonal skills in building and maintaining crucial relationships including support to Quality Staff and revenue cycle team.
Participates in the analysis and trending of statistical data to identify opportunities for improvement and innovation.
Educates care providers on documentation best practices annual coding and regulatory updates.
Communicates clearly concisely and in a compelling manner to effectively engage others.
Achieves and maintains key operating metrics consistent with CDI program/department requirements.
Acts as a back up to the CDI Supervisor/Coordinator.
Assist with monitoring and reporting key metric goals including but not limited to process measures Record Review Rate Query Rate DRG Match Rate Query Response Rate Query Agreement Rate Query Impact CMI Claims Denials Rate CC/MCC rates.
Obtains continuing education to maintain credentials and stay abreast of current trends in the healthcare field and emerging technologies.
Adheres to and follows all patient experience initiatives.
Reports to and departs from work on time and as scheduled.
Performs other duties as assigned.
Must be able to deal with stress while maintaining composure.
Follows and adheres to TRMC vaccine policy(s) mandated by the Centers for Medicare & Medicaid Services (CMS).
Skills/Competencies
Critical thinking skills
Ability to manage multiple priorities
Ability to work independently
Ability to identify opportunities
Excellent verbal and written communication skills
Ability to work with multiple technologies both current and emerging including MS Word Excel and
Powerpoint.
Classification: Salaried/Exempt
FLSA Category: Administrative Exemption
Job Category: 2 Professionals
Position Summary
Working independently the Clinical Documentation Integrity (CDI) Specialist performs/ initial/ concurrent/retrospective reviews of the health record to ensure the capture of complete and accurate provider documentation. As appropriate generates and issues compliant queries to clarify documentation that is incomplete conflicting or ambiguous. Initiates contact with physicians to obtain complete and timely query responses. Educates care providers on documentation best practices. This includes but is not limited to capturing the clinical picture of a patient through complete and accurate documentation for correct code/DRG assignment accurate quality measure reporting appropriate reimbursement and accurate risk adjusted scores.
The Clinical Documentation Integrity (CDI) Specialist carries out the operational performance of the defined Clinical Documentation Integrity (CDI) program.
Essential Functions
Conducts initial and extendedstay concurrent reviews on selected admissions consistent with program/department volume and frequency requirements. Documents and reviews other pertinent information in designated systems.
Analyzes documented and clinically supported conditions in the health record to ensure the capture of accurate and completion documentation resulting in final code/DRG assignment with the highest degree of specificity and accuracy.
Demonstrates knowledge of the ICD10CM/PCS Official Guidelines for Coding and Reporting and the DRG classification systems to ensure compliance with regulatory requirements related to CDI and coding functions.
Using critical thinking skills and clinical judgement determines when and/or if a provider query is necessary in accordance with the ACDISAHIMA Practice Brief titled Guidelines for Achieving a Compliant Query Practice.
Uses clinical judgement to determine appropriate and relevant clinical indicators and/or reasonable diagnostic options to formulate patient specific queries per Query Policy.
Physician queries are generated to assist and improve the quality of the documentation.
Collaborates with coding professionals to support clinical code/DRG assignment and resolve identified discrepancies.
Develops collaborative relationships and possesses excellent interpersonal skills in building and maintaining crucial relationships including support to Quality Staff and revenue cycle team.
Participates in the analysis and trending of statistical data to identify opportunities for improvement and innovation.
Educates care providers on documentation best practices annual coding and regulatory updates.
Communicates clearly concisely and in a compelling manner to effectively engage others.
Achieves and maintains key operating metrics consistent with CDI program/department requirements.
Acts as a back up to the CDI Supervisor/Coordinator.
Assist with monitoring and reporting key metric goals including but not limited to process measures Record Review Rate Query Rate DRG Match Rate Query Response Rate Query Agreement Rate Query Impact CMI Claims Denials Rate CC/MCC rates.
Obtains continuing education to maintain credentials and stay abreast of current trends in the healthcare field and emerging technologies.
Adheres to and follows all patient experience initiatives.
Reports to and departs from work on time and as scheduled.
Performs other duties as assigned.
Must be able to deal with stress while maintaining composure.
Follows and adheres to TRMC vaccine policy(s) mandated by the Centers for Medicare & Medicaid Services (CMS).
Skills/Competencies
Critical thinking skills
Ability to manage multiple priorities
Ability to work independently
Ability to identify opportunities
Excellent verbal and written communication skills
Ability to work with multiple technologies both current and emerging including MS Word Excel and
Powerpoint.
Work Experience
Three 3 to Five 5 Years experience in an acute care facility in HI/Inpatient Coding Case Management Nursing Quality Reviewer and/or other related field.
Be familiar with coding as it relates to documentation
Working knowledge of laws rules and regulations regarding utilization review and discharge planning functions of government programs such as Medicare Medicaid and Medicare Advantage and Commercial payers.
Experience/knowledge of regulatory compliance issues facing the healthcare industry
Experience with 3M and EPIC preferred.
Education
Clinical experience including RN/BSN/MSN is highly desired.
Associates degree required. Bachelors or masters degree from an accredited college/university is
Preferred
Obtain CDI credential within three 3 years of employment CDIP CCDS preferred.
One or more RHIT RHIA COC CPC CHRI and/or CCDS certifications are recommended but not
required.
Physical Demands and Work Environment
Lifting/Carrying Pushing/Pulling
Lbs. Time Lbs. Time
110 3
1 033
2 033
5 033
760 033
Movement Time
Bend/Stoop/Twist 033
Crouch/Squat 033
Kneel/Crawl 033
Reach above Shoulder 033
Reach below Shoulder 033
Repetitive Arm None
Repetitive Hand 033
Grasping 033
Squeezing 033
Climb Stairs None
Walking Uneven 033
Walking Even 3466
Environment Time
Indoors 67100
Outdoors 033
Extreme Heat None
Dusty None
Excessive Noise 033
Equipment Time
Motor Vehicles None
Foot Pedals None
Extreme Heat None
Dusty None
Excessive Noise 033
Work near Time
Machinery None
Electricity None
Sharps 033
Chemicals 033
Fumes 033
Heights None
Vision
Depth Perception Required
< 20 Required
Color Not Required
Peripheral Required
Endurance Hours at Once Total in 12HR
Sit 1 3
Stand 4 4.5
Walk 4 4.5
Required Experience:
Unclear Seniority
Employment Type
Full-Time
Key Skills
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