JOB SUMMARY

The CDI Specialist supports accurate, complete, and timely clinical documentation in the medical record. This role works with providers, nurses, coders, and other care team members to ensure documentation clearly reflects the patient’s severity of illness, risk of mortality, care provided, and clinical decisionmaking. The CDI Specialist promotes ethical documentation practices that meet regulatory requirements and support quality reporting, patient outcomes, and appropriate reimbursement.

JOB DEMANDS

• Works independently with minimal supervision while collaborating with a multidisciplinary team
• Adapts to ongoing changes in healthcare regulations, documentation standards, and technology
• Maintains strict patient confidentiality at all times
• Demonstrates accountability, professionalism, and timely followthrough
• May work flexible hours based on organizational needs

ESSENTIAL JOB FUNCTIONS

Each position will be responsible for any additional tasks and responsibilities outlined in the specific department, position or orientation checklist.

General:

• Adheres to all hospital policies, procedures, and regulatory requirements.
• Responds appropriately and effectively to emergency situations in accordance with hospital protocols.
• Demonstrates respect, trust, safety, confidentiality, and cooperation in all interactions with patients, families, practitioners, and colleagues.
• Provides excellence in internal and external customer service and maintains a positive image of the hospital at all times.

Role-Specific:

• Reviews inpatient medical records concurrently to identify unclear, incomplete, or conflicting documentation
• Initiates compliant, clinically supported provider queries using approved CDI standards and organizational policy
• Collaborates with providers, nursing staff, case management, utilization review, coding, and quality teams
• Ensures documentation accurately reflects diagnoses, treatment, severity of illness, risk of mortality, and risk adjustment
• Follows AHIMA, ACDIS, CMS, and payer documentation and coding guidelines
• Practices CDI work in alignment with the AHIMA Code of Ethics, including honesty, accuracy, integrity, confidentiality, and respect for patients
• Uses only clinical indicators supported by the health record; does not request documentation of diagnoses that are not clinically supported
• Ensures all provider queries are nonleading, factual, and focused on clarification of the clinical record
• Avoids pressure related to reimbursement, productivity, or performance measures
• Supports documentation that reflects the true clinical picture of the patient
• Tracks and follows up on provider queries to support timely response and completion
• Assists coding staff by clarifying clinical indicators needed for accurate code assignment
• Identifies documentation trends, risks, and opportunities for improvement
• Provides education to providers and staff on documentation best practices, ethical CDI standards, and regulatory updates
• Supports quality reporting, utilization review, and outcome measurement efforts
• Uses electronic health record and CDI software systems to document reviews, outcomes, and metrics
• Participates in audits, compliance activities, performance improvement efforts, and special projects as assigned
• Reports compliance or ethical concerns through appropriate organizational channels

• JOB QUALIFICATIONS

  Education:

• Clinical or health information background preferred. Graduate of an accredited school of nursing requred.

• Certifications/Licenses:

• RN, CCDS, CDIP, RHIA, RHIT, or other related credential preferred or required per department policy.

• Job Knowledge and Skills:

• Strong understanding of clinical documentation and disease processes.
• Knowledge of ICD10CM/PCS coding principles and CDI workflows.
• Familiarity with CMS, payer, and regulatory documentation requirements.
• Strong written and verbal communication skills.
• Ability to analyze clinical data and recognize documentation gaps.
• Proficient in electronic health records and common computer software.
• Ability to work professionally with providers and multidisciplinary teams.