Clinical Documentation Improvement (CDI) Specialist

You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.


Job Summary


We are seeking a detail-oriented Clinical Documentation Improvement (CDI) Specialist to join our client team. In this role, you will review inpatient medical records to ensure clinical documentation accurately reflects the patient's severity of illness and risk of mortality, acting as a liaison among clinical providers, nursing staff, and Health Information Management (HIM)/coding teams.


Key Responsibilities

• Conduct comprehensive concurrent and retrospective medical record reviews to evaluate clinical documentation completeness and accuracy.
• Identify documentation gaps, ambiguities, or inconsistencies and formulate clear, compliant physician queries when necessary.
• Collaborate with physicians, mid-level providers, and clinical care teams to educate them on clinical documentation integrity and coding guidelines.
• Ensure health record documentation supports proper code assignment, Severity of Illness (SOI), Risk of Mortality (ROM), and Diagnosis Related Group (DRG) assignment.
• Monitor and adhere to official ICD-10-CM/PCS coding guidelines, CMS rules, and institutional compliance standards.
• Participate in interdisciplinary team meetings and CDI committee initiatives to drive continuous quality improvement.

Qualifications

• Active and valid Registered Nurse (RN) license.
• CCDS (Certified Clinical Documentation Specialist) OR CDIP (Certified Documentation Improvement Practitioner) credential required.
• Deep clinical knowledge of disease processes, medical terminology, pharmacology, and clinical indicators.
• Comprehensive understanding of ICD-10-CM/PCS, MS-DRG, APR-DRG, and coding compliance guidelines.
• Excellent written and verbal communication skills.

Experience

• Minimum of 3+ years of direct Clinical Documentation Improvement (CDI) experience in an acute care hospital setting.

Skills

• Experience with electronic health record (EHR) systems (e.g., Epic, Cerner) and CDI querying software.

Location

• Remote

Shift options

• 7:00 AM - 3:00 PM EST
• 8:00 AM - 4:00 PM

Benefits

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
• Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
• 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
• Short Term Disability Insurance.
• Term Life Insurance Plan.

* We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).


Medix Overview:


With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we're dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.


Any required state or Joint Commission training is compensated at the state or local minimum wage rate.


* As a job position within our Revenue Cycle division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, handling financial and other payment data, and working within departments that care for vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.