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Responsibilities

The CDI Specialist is responsible for reviewing inpatient medical records to ensure clinical documentation accurately reflects the patient's severity of illness, risk of mortality, diagnoses, procedures, and quality of care. The role collaborates closely with physicians, coders, and healthcare teams to improve documentation quality, support accurate coding, optimize reimbursement, and ensure compliance with regulatory guidelines.

Job Requirements

• Registered Nurse (RN) or USRN with a strong clinical background

• At least 1 year of experience in Clinical Documentation Improvement (CDI), medical coding, or clinical documentation review

• Strong knowledge of ICD-10-CM/PCS, DRGs, CC/MCCs, and clinical indicators

• Familiarity with quality measures, SOI/ROM, and reimbursement methodologies

• Excellent written and verbal communication skills

• Detail-oriented with strong analytical and problem-solving skills