Clinical Documentation Specialist (CDI)

About This Role

This Clinical Documentation Integrity (CDI) Specialist role involves reviewing inpatient medical records to ensure accurate, complete, and compliant clinical documentation. The position focuses on reflecting severity of illness (SOI), risk of mortality (ROM), quality outcomes, medical necessity, and appropriate reimbursement. It suits a specialist who can collaborate with physicians, coding professionals, and other healthcare team members to improve documentation quality and support accurate code assignment and DRG integrity.

Responsibilities

• Perform concurrent and/or retrospective reviews of inpatient medical records for documentation accuracy, completeness, and compliance
• Maintain an accuracy rate of 98%
• Identify opportunities for clarification of diagnoses, procedures, present on admission (POA) indicators, severity of illness, risk adjustment, and clinical validation
• Initiate compliant physician queries to clarify conflicting, incomplete, or nonspecific documentation
• Collaborate with coding staff to ensure accurate ICD-10-CM/PCS coding and MS-DRG/APR-DRG assignment
• Monitor documentation trends related to mortality, quality indicators, hospital-acquired conditions (HACs), patient safety indicators (PSIs)
• Conduct clinical validation reviews for diagnoses such as sepsis, respiratory failure, encephalopathy, malnutrition, acute kidney injury, and other high-risk conditions
• Maintain productivity and quality standards established by Solventum/facility (query rate of 35-40%, review rate of 20-25 cases per day, and an accuracy rate of 98%)
• Participate in multidisciplinary rounds, provider education, and documentation improvement initiatives
• Assist with denial prevention by supporting documentation integrity initiatives
• Stay current with CMS, ICD-10, AHA Coding Clinic, and organizational compliance standards

Requirements

• Valid Registered Nurse license with a bachelor’s degree or higher (completed and verified prior to start)
• Seven (7) years of Nursing experience
• Five (5) years of experience in the inpatient acute care setting
• Experience auditing practices, ICD 10, PCS guidelines, quality initiatives, and MS-DRG and APR DRG methodologies
• Clinical knowledge and application to coding
• Experience in CCDS, CCS, or CDIP with seven (7) years of clinical documentation/DRG validator

Nice to have:

• Experience with telecommuting, working with EMRs and other electronic tools with current chart auditing skills
• Knowledgeable in Solventum HIS software portfolio (360 Encompass)
• Proficient in Microsoft Word, Excel, PowerPoint, and other Microsoft Office programs
• Excellent verbal, written, presentation, analytical, and organizational skills