Clinical Documentation Integrity (CDI) Specialist
Core
Review inpatient medical records to improve the accuracy, completeness, and clinical integrity of documentation, ensuring diagnoses and procedures reflect care provided.
Role type
Clinical Documentation Integrity (CDI) Specialist
Builds
Accurate medical documentation and appropriate MS-DRG assignments for inpatient care
Domain
Healthcare / Medical Coding & Documentation
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical validation principles, ACDIS/AHIMA compliant query guidelines, MS-DRG assignment, Patient Safety Indicators, Hospital-Acquired Conditions, Severity of Illness, Risk of Mortality, present-on-admission status, ICD-10 coding, EHR systems, CDI software, electronic encoders, medical terminology, anatomy, physiology, microbiology
Preferred skills
CCDS or CDIP certification, advanced degree
Technologies
CDI applications, electronic coding references, Official Coding Guidelines, Coding Clinic resources, encoder systems
Responsibilities
Conduct comprehensive initial and follow-up concurrent reviews of inpatient medical records; Identify incomplete, conflicting, or clinically unclear documentation and determine appropriate opportunities for clarification; Apply clinical validation principles and current ACDIS/AHIMA compliant query guidelines when preparing written queries for treating physicians; Identify principal and secondary diagnoses and significant procedures to establish and update the appropriate working MS-DRG; Monitor documentation throughout concurrent reviews and update working DRGs and expected length-of-stay considerations; Track physician responses to queries and ensure all relevant outcomes and documentation are accurately captured in the appropriate systems; Collaborate with coding teams on ICD-10 coding questions, MS-DRG assignments, concurrent and retrospective queries, and DRG reconciliation; Contribute to departmental committees, hospital task forces, service-line meetings, and other assigned initiatives
Seniority
Mid-level, hands-on IC