Clinical Documentation Improvement Specialist

Overview

We are seeking a Clinical Documentation Improvement (CDI) Specialist for a U.S.-based role supporting inpatient healthcare operations. In this position, you will help strengthen the accuracy, completeness, and overall quality of clinical records. You will partner with physicians, coders, and other healthcare professionals to make sure documentation properly reflects patient acuity, complexity of care, and outcomes. The role blends clinical knowledge with documentation and coding expertise to support compliance, reimbursement accuracy, and quality reporting. It also includes opportunities to improve workflows, educate staff, and contribute to reviews tied to patient safety and quality metrics. This is a strong opportunity for an experienced nursing professional who wants to influence healthcare quality and operational performance.

Responsibilities

• Review inpatient charts concurrently and after discharge to find opportunities to improve documentation quality and coding precision.
• Send physician queries and work with providers to resolve unclear, incomplete, or inconsistent notes so the record supports accurate coding and clinical interpretation.
• Promote documentation that clearly captures severity of illness, risk of mortality, complexity of care, case mix index, length of stay, and resource use.
• Train physicians, clinical staff, and other stakeholders on documentation expectations, coding rules, reimbursement requirements, and regulatory standards.
• Use coding concepts, reimbursement guidelines, and documentation rules to support correct working DRG assignments and CDI integrity.
• Partner with coding professionals, auditors, quality improvement teams, and other stakeholders to address documentation gaps and improve data quality.
• Perform targeted reviews related to mortality, patient safety indicators, and other quality or compliance priorities assigned by leadership.
• Keep up with changing documentation, coding, and regulatory requirements to maintain compliance and best practices.
• Support onboarding, training, and mentoring for new members of the CDI team.
• Help drive continuous improvement efforts that raise documentation quality, reporting accuracy, and operational efficiency.

Requirements

• Associate degree in Nursing is required; a BSN is preferred.
• An active, unrestricted U.S. RN license is required.
• Three to five years of recent clinical experience in med-surg, ICU, telemetry, emergency department, or a similar acute care environment.
• Solid understanding of CDI practices, coding methods, reimbursement structures, and healthcare quality measures.
• Experience using electronic medical record systems and CDI technology platforms.
• Working knowledge of CMS rules, coding guidance, compliance standards, and healthcare documentation expectations.
• Strong analytical, critical thinking, and problem-solving abilities for complex clinical situations.
• Clear written and verbal communication skills, with the ability to educate providers and care teams effectively.
• Ability to work independently, juggle multiple priorities, and perform well in a fast-paced healthcare setting.
• Proficiency in Microsoft Word, Excel, PowerPoint, and Outlook.
• Professional judgment, adaptability, strong interpersonal skills, and a commitment to ongoing learning.

Benefits

• Annual pay between $48,131 and $81,225.49, depending on experience, qualifications, location, and job-related skills.
• Eligibility for an annual performance bonus with a target incentive opportunity.
• Medical, healthcare, and wellness coverage.
• Retirement savings support and financial wellbeing programs.
• Paid time off along with company-observed holidays.
• Learning, development, and career growth opportunities.
• A collaborative and supportive workplace focused on innovation and continual improvement.
• The chance to contribute to meaningful healthcare initiatives that improve patient outcomes and organizational results.
• Exposure to cross-functional teams and changing healthcare technologies and processes.

Additional Information

This role is listed on behalf of a partner organization that will handle applications and next steps. The hiring process may include AI-assisted tools to support application review, resume analysis, and response evaluation; these tools do not replace human judgment, and final hiring decisions are made by people.

Data Privacy Notice

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