Clinical Documentation Improvement Specialist

Clinical Documentation Improvement (CDI) Specialist – Inpatient

With five decades of experience, Shepherd Center provides world-class clinical care, research, and family support for people experiencing the most complex conditions, including spinal cord and brain injuries, multi-trauma, traumatic amputations, stroke, multiple sclerosis, and pain. An elite center ranked by U.S. News as one of the nation's top hospitals for rehabilitation, Shepherd Center is also recognized as both Spinal Cord Injury and Traumatic Brain Injury Model Systems. Shepherd is the only rehabilitation facility in the nation with an intensive care unit on-site, allowing us to care for the most complex patients and begin the rehabilitation process sooner. Shepherd Center treats thousands of patients annually with unmatched expertise and unwavering compassion to help them begin again.

Shepherd Center's culture is one of hope, humor, and hard work. You will enjoy career growth, strong relationships with co-workers, strong support from leadership, and fun activities that have kept over 12% of staff members working at Shepherd for more than 20 years.

The Clinical Documentation Improvement (CDI) Specialist – Inpatient plays a critical role in ensuring the accuracy, completeness, and integrity of clinical documentation within the medical record. This position partners with physicians, coding professionals, and interdisciplinary teams to improve documentation quality, support compliant coding and reimbursement, and enhance the reliability of quality reporting. The ideal candidate has experience in inpatient CDI or coding, strong knowledge of clinical documentation standards, and the ability to collaborate effectively with providers in a fast-paced healthcare environment.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient medical records to evaluate documentation accuracy, completeness, and compliance
• Identify opportunities to improve documentation related to diagnoses, procedures, severity of illness (SOI), and risk of mortality (ROM)
• Create and issue compliant provider queries to clarify documentation Collaborate with physicians, nursing staff, and coding professionals to support accurate clinical documentation
• Ensure alignment with ICD-10-CM coding guidelines, CMS regulations, and organizational policies Utilize Epic CDI tools, work queues, and reporting dashboards to manage workload and track performance
• Monitor documentation trends and escalate opportunities for improvement
• Partner with Coding, Quality, Compliance, and Revenue Cycle teams to support documentation integrity

Qualifications

· Associate or Bachelor's degree in Health Information Management, Nursing, or related healthcare field (or equivalent experience)

· One of the following credentials required:

o RHIA, RHIT, or CCS

o CDIP, CCDS, or CDEO

o RN or LPN

Experience

· Minimum of 3–5 years of experience in CDI, inpatient coding, or related HIM function

· Acute care inpatient experience required

· Experience with Epic CDI or similar CDI systems preferred

Knowledge & Skills

· Strong understanding of ICD-10-CM coding and clinical documentation standards

· Knowledge of MS-DRG, APR-DRG, SOI/ROM, and risk adjustment concepts

· Experience with compliant query practices

· Strong communication skills and ability to engage providers

· Ability to analyze clinical documentation for accuracy and completeness