Clinical Documentation Improvement, CDI Specialist
Exceptional Healthcare Inc.
full-time
Posted on:
Location Type: Remote
Location: United States
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About the role
- Review inpatient medical records to identify documentation gaps and improvement opportunities
- Craft physician queries that clarify diagnoses and procedures
- Educate providers on documentation best practices and regulatory requirements
- Monitor key metrics including CMI trends and query response rates
- Support denial management with clinical justifications for appealed claims
- Collaborate with coding teams for accurate DRG assignment
- Develop documentation policies aligned with CIHQ accreditation standards
Requirements
- Associate or bachelor's degree in Nursing, HIM, or a related healthcare field
- 3+ years of clinical experience in acute care (ER, ICU, med-surg, or case management preferred)
- 2+ years of CDI experience with concurrent review and physician querying
- Active, unencumbered RN license (if nursing background)
- RN, RHIA, RHIT, CCS, CCDS, CDIP, or related certification preferred
- Strong knowledge of CMS, AHIMA, and ACDIS standards
Benefits
- Clinical documentation improvement opportunities
- Collaboration with physicians and coding teams
- Education and coaching on best practices
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical documentation improvementphysician queryingdocumentation best practicesdenial managementDRG assignmentCMI trends monitoringdocumentation policies developmentregulatory requirementsacute care experienceconcurrent review
Soft Skills
collaborationeducationcommunication
Certifications
RN licenseRHIARHITCCSCCDSCDIP