Position Summary:
The CDI Specialist improves the accuracy, clarity, and completeness of clinical documentation across inpatient, same-day surgery, observation, and emergency encounters. This role conducts concurrent medical record reviews, identifies opportunities to strengthen documentation, and works collaboratively with physicians, clinical staff, and HIM coding teams to ensure clinical severity, patient conditions, and services provided are clearly and accurately reflected. The CDI Specialist supports high-quality patient care by promoting documentation practices that align with true clinical acuity, support appropriate coding, and provide reliable data for reporting and outcomes measurement. Through ongoing education, effective communication, and expert clinical analysis, the position plays an important role in strengthening compliance, quality metrics, and overall organizational performance.
Key Responsibilities:
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Perform concurrent clinical documentation reviews to evaluate accuracy, completeness, and clinical relevance of diagnoses, procedures, and supporting indicators.
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Collaborate with providers, nursing staff, Clinical Excellence and Patient Safety (CEPS), and HIM coding teams to clarify documentation and ensure severity of illness and risk of mortality are appropriately reflected.
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Initiate and track documentation queries in accordance with organizational guidelines and regulatory expectations.
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Analyze working DRGs/APCs and recommend documentation updates needed for accurate coding, reimbursement, and quality reporting.
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Educate providers and clinical staff on documentation best practices, regulatory requirements, and opportunities for improvement.
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Maintain organized documentation, reporting, and communication workflows to support CDI program goals and performance monitoring.
Licenses and Certifications Required:
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Current or temporary RN license in ND or compact RN licensure or Licensed Practical Nurse or LPN designation required; OR Certified Clinical Documentation Specialist (CCDS) from ACDIS or Clinical Documentation Improvement Professional (CDIP) from AHIMA required.
Educational Requirements:
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Associate or Bachelor’s Degree in Nursing required; OR Associate or Bachelor’s Degree in Health Information Management (RHIT or RHIA) or other Clinical Healthcare field required.
Experience Requirements:
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A minimum of 3+ years clinical experience in an acute care or outpatient (Same Day Surgery, Emergency Room or Observation) setting is required; OR a minimum of 5+ years acute care, same day surgery, ER or observation) coding experience required.
Special Skills or Training Requirements:
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Dependable, self directed. Critical thinking, problem solving, organizational and deductive reasoning skill.
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Knowledge of age specific needs and the elements of disease processes and related procedures.
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Strong broad based clinical knowledge an understanding of pathology/physiology of disease processes.
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Knowledge of medical record documentation requirements and computer literacy is required.
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Excellent written and verbal communication skills. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.
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Willingness to learn and incorporate knowledge into day to day working environment: Knowledge of inpatient admission criteria; Understanding of complications, comorbidities, severity
Physical Requirements:
The CDI Specialist primarily works in an office or remote setting that requires prolonged periods of sitting, computer use, and detailed review of electronic medical records. The role may involve occasional standing, walking, or light lifting of reference materials. Adequate vision, hearing, and communication abilities are essential for reviewing complex clinical information and collaborating effectively with providers and interdisciplinary staff.
Environmental Requirements:
Work is performed in a professional office or remote environment with routine exposure to computers, electronic medical record systems, and typical office noise. Occasional entry into clinical areas may be required for provider consultation or information gathering, necessitating adherence to infectioncontrol and safety protocols. Strict compliance with confidentiality, HIPAA, and organizational policies is required when handling sensitive patient information.
