Clinical Documentation Improvement Specialist

Responsibilities

The Clinical Documentation Integrity (CDI) Specialist is responsible for conducting concurrent reviews of inpatient medical records to ensure accurate, complete, and compliant clinical documentation. This role focuses on identifying missing or understated diagnoses, facilitating physician queries, and collaborating with cross-functional teams to ensure the medical record reflects the true acuity of the patient and supports appropriate care, coding, and quality outcomes. The position requires strong clinical expertise, critical thinking, and effective communication with providers and internal stakeholders.

 

Job Responsibilities 

• Conduct initial and follow-up concurrent reviews of inpatient medical records to identify opportunities for improved documentation
• Analyze clinical indicators to identify diagnoses or conditions not yet documented in the record
• Determine and validate the appropriate principal and secondary diagnoses to accurately reflect patient acuity
• Initiate and follow up on physician queries (written and verbal) to obtain complete and accurate documentation
• Build and maintain strong working relationships with physicians to facilitate effective communication and documentation improvement
• Provide education to physicians on documentation best practices, both in group settings and one-on-one
• Document review findings and key information within workflow and tracking tools
• Collaborate with Coding, HIM, and other departments to ensure alignment on documentation and level of care
• Utilize data and feedback from leadership to prioritize focus areas and improve performance
• Manage daily responsibilities effectively, maintaining flexibility in a fast-paced environment

Required Qualifications

• Current RN, PA, or NP license in NYS
• Minimum of 3 years of clinical experience in an acute care setting (e.g., inpatient bedside nursing, case management)
• Strong clinical knowledge, including pathology and physiology
• Excellent written and verbal communication skills
• Strong critical thinking skills
• Working knowledge of inpatient admission criteria
• Ability to work independently and manage time effectively in a deadline-driven environment

 

Desired Attributes

• Prior Clinical Documentation Integrity (CDI) experience (preferred but not required)
• Ability to think proactively and identify gaps in documentation
• Strong interpersonal skills and ability to build rapport with physicians
• Assertiveness and confidence in provider communication
• Attention to detail and commitment to documentation accuracy
• Adaptability, flexibility, and ability to prioritize competing demands
• Demonstrated enthusiasm and engagement in achieving organizational goals

 

Deliverables

• Accurate and timely concurrent reviews of inpatient charts
• Identification and documentation of missing or incomplete diagnoses supported by clinical indicators
• Completed and tracked physician queries with appropriate follow-up
• Improved completeness and accuracy of medical records reflecting patient acuity and level of care
• Clear and concise documentation within CDI workflow tools
• Ongoing physician education and engagement in documentation practices
• Contribution to improved coding accuracy, quality metrics, and organizational outcomes

 

Pay Range

USD $105,000.00 - USD $150,000.00 /Yr.