The Clinical Documentation Integrity (CDI) Specialist is responsible for reviewing and analyzing medical records to identify opportunities for clarifying diagnoses and procedures for each patient encounter. This role works collaboratively with providers, interdisciplinary clinical staff, and the coding team to ensure the medical record accurately reflects the patient’s clinical picture, severity of illness, quality of care, and appropriate utilization—supporting compliant reimbursement and accurate reporting of outcomes.
Performs thorough initial and follow-up concurrent reviews of assigned patient records according to established CDI timelines, prioritization criteria, and team workflows.
Identifies incomplete, inconsistent, unclear, or conflicting documentation and clarifies diagnostic accuracy within the medical record.
Applies foundational principles of clinical validation and understands how to construct compliant provider queries.
Drafts and submits compliant queries to treating physicians using the most current ACDIS/AHIMA Guidelines to Achieving a Compliant Query Process.
Determines potential principal diagnoses, secondary diagnoses, and significant procedures for assignment of the working MS-DRG.
Establishes and updates the working DRG and expected length of stay throughout the review process based on evolving documentation.
Utilizes organization-approved query templates and follows 2022 ACDIS/AHIMA compliant query standards.
Includes only relevant, patient-specific, and clinically supported indicators when constructing query options.
Ensures that all choices within a query represent reasonable, clinically supported conclusions based on the patient’s record.
Demonstrates understanding of Patient Safety Indicators (PSIs), Hospital-Acquired Conditions (HACs), Severity of Illness (SOI), Risk of Mortality (ROM), and present-on-admission (POA) requirements.
Appropriately applies approved clinical indicators for specific diagnoses in alignment with hospital policies and clinical standards.
Adheres to facility procedures regarding documentation requirements, query escalation processes, DRG reconciliation, and other CDI-related workflows.
Tracks provider responses and ensures query outcomes are accurately documented in the medical record.
Meets established productivity standards and quality performance benchmarks.
Maintains competency in CDI software systems to manage worklists, document review outcomes, submit queries, and track responses.
Inputs all necessary information into CDI and/or related systems to support coders and CDI/coding auditors with final MS-DRG, SOI, and ROM determination.
Demonstrates proficiency in electronic coding tools to assign working MS-DRGs, SOI, and ROM, and references Official Coding Guidelines and Coding Clinic updates to ensure coding accuracy.
Collaborates with the coding team on questions related to ICD-10 coding, MS-DRG assignment, and both concurrent and retrospective query processes.
Actively participates in the DRG reconciliation process with coders in a timely and collaborative manner.
Participates in departmental and hospital committees, task forces, and service line meetings as needed.
Contributes to a positive, professional, and team-oriented work environment.
Maintains compliance with HIPAA regulations and organizational code of conduct standards.
Graduation from an accredited School of Nursing.
Bachelor’s or Master’s degree in a health-related field with an active/current professional license OR graduation from an accredited medical school (MD) OR RHIA, RHIT, or CCS certification with an active/current credential.
Must hold at least one of the following active credentials: RN, MD (or equivalent), RHIA, RHIT, or CCS.
2–4 years of experience in acute care inpatient hospital coding or Clinical Documentation Integrity.
Proficiency with encoder tools and MS-DRG assignment processes.
Ongoing working knowledge of Official Coding Guidelines and current Coding Clinic updates.
CCDS or CDIP certification strongly preferred.
Robust clinical understanding of disease processes.
Demonstrated critical thinking, strong analytical abilities, and effective problem-solving skills.
Solid knowledge of medical terminology, anatomy, physiology, microbiology, and pathophysiology.
Excellent verbal and written communication skills, with the ability to communicate tactfully and effectively.
Comfortable engaging with physicians in complex or challenging discussions.
Strong keyboarding and computer proficiency, including experience with EHR platforms, CDI software applications, and encoder tools.
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