Job Summary: The CDI Specialist reviews inpatient medical records to ensure clinical documentation accurately reflects the severity of illness, treatments delivered, and diagnoses rendered. Working directly with physicians, nursing staff, and coders in a community hospital setting, this role improves documentation through concurrent record review, compliant physician queries, and provider education. The CDI Specialist directly impacts reimbursement accuracy, quality reporting, and patient outcomes.

Job Responsibilities/Duties:

1. CLINICAL DOCUMENTATION REVIEW

• Conduct concurrent and/or retrospective medical record reviews to assess documentation accuracy, completeness, and specificity.
• Identify documentation opportunities to clarify diagnoses, procedures, complications, comorbidities, and clinical indicators.
• Ensure documentation supports medical necessity and accurate MS-DRG/APR-DRG assignment.
• Serve as a technical expert in health record content and documentation requirements within the EHR.

1. PROVIDER COLLABORATION & QUERY PROCESS

• Initiate compliant, non-leading queries to physicians and providers to obtain clarification of diagnoses and procedures.
• Collaborate with coders to ensure discharge diagnoses accurately capture clinical status and care delivered.
• Educate providers on documentation best practices, coding guidelines, and regulatory requirements.
• Foster positive working relationships with medical staff to support documentation improvement initiatives.

1. REGULATORY COMPLIANCE & QUALITY

• Ensure documentation complies with CMS, AHIMA, ACDIS, and other regulatory standards.
• Monitor and support quality metrics, including case mix index (CMI), hospital-acquired conditions (HACs), PSI indicators, and value-based purchasing measures.
• Maintain audit-ready documentation practices.
• Develop and update documentation policies in alignment with CIHQ accreditation standards.

1. DATA ANALYSIS & REPORTING

• Track and report key CDI metrics such as query response rate, agreement rate, CMI trends, and financial impact.
• Participate in internal audits and performance improvement initiatives.
• Identify trends and recommend workflow or educational improvements.

EDUCATION & TRAINING:

• Provide ongoing education to providers and staff regarding documentation guidelines and regulatory updates.
• Support denial management by providing clinical justifications for appealed claims.
• Perform other duties as assigned.

QUALIFICATIONS & EXPERIENCE

• Associate or bachelor’s degree in nursing, Health Information Management, or related healthcare field required.
• RN, RHIA, RHIT, CCS, CCDS, CDIP, or other relevant certification preferred (or required within a specified timeframe).
• Minimum 3 years clinical experience in acute care; ER, ICU, med-surg, or case management preferred.
• Minimum 2 years CDI experience with concurrent record review and physician querying.
• Current unencumbered RN license in the state of practice (if nursing background).
• CCDS (ACDIS) or CDIP (AHIMA) certification preferred.
• Additional coding credentials (CCS, CPC, CIC) a plus.

PHYSICAL DEMANDS

• Prolonged sitting at a desk and working on a computer for medical record review.
• Adequate vision, hearing, and repetitive hand/wrist motions required.
• Ability to move about the facility for physician rounding and training sessions.

WORK CONDITIONS

• Well lighted, heated and/or air-conditioned indoor clinical/office setting with adequate ventilation.
• On-site
• Travel to ECH hospital locations may be required.