Clinical Documentation Improvement Specialist

Position Summary The Clinical Documentation Improvement (CDI) Specialist serves as a key liaison between providers and coding professionals, ensuring accurate, complete, and compliant clinical documentation. This individual will leverage strong clinical knowledge and expertise in ICD-10 coding guidelines to improve documentation quality, optimize reimbursement, and support quality reporting initiatives. Responsibilities Apply advanced clinical knowledge of disease processes, differential diagnoses, pathophysiology, and treatment protocols to support documentation improvement. Demonstrate expertise in ICD-10-CM/PCS coding guidelines and documentation standards. Serve as the clinical liaison between providers and coding professionals to ensure accurate translation of clinical documentation into coding terminology. Educate providers on documentation best practices in accordance with ICD-10-CM/PCS Official Coding Guidelines. Conduct medical record reviews and audits to ensure documentation accurately reflects patient severity of illness, risk of mortality, and appropriate code assignment. Collaborate with physicians, coding professionals, hospital leadership, quality, compliance, and interdisciplinary clinical teams. Develop and deliver educational presentations and provider training sessions. Utilize DRG grouper software and electronic medical record systems to support documentation improvement initiatives. Partner with inpatient coding teams to facilitate accurate APR-DRG and MS-DRG assignment. Prepare clinical appeal letters and assist with denial management activities. Create compliant physician queries consistent with AHIMA query guidelines. Monitor CDI performance metrics, identify documentation trends, and recommend process improvements. Work with Clinical Applications teams to enhance EMR workflows supporting accurate provider documentation. Present CDI program metrics and recommendations to hospital leadership. Participate in departmental and interdisciplinary CDI meetings and initiatives. Maintain compliance with HIPAA, regulatory requirements, organizational policies, and industry best practices. Qualifications Education MD (Doctor of Medicine) DO (Doctor of Osteopathic Medicine) MBBS/ECFMG Certification Certifications ACDIS Certified Clinical Documentation Specialist (CCDS) AHIMA Certified Coding Specialist (CCS) Experience Minimum 5 years of inpatient Clinical Documentation Improvement (CDI) experience. Minimum 3 years of direct clinical experience managing patients in an acute care setting. Strong understanding of inpatient coding, DRG methodologies, clinical documentation standards, and regulatory requirements. Experience working with electronic medical records such as Epic, Meditech, or similar platforms is preferred. Excellent communication, collaboration, analytical, and presentation skills. #J-18808-Ljbffr SpineSearch LLC