About this role
<div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px"><u><b>Job Summary</b></u></H2> </div><div><p><span style="font-size:10.0pt;font-family:Arial, sans-serif">The Clinical Documentation Improvement (CDI) Specialist is responsible for improving the quality, accuracy, and completeness of clinical documentation within the patient medical record. The role focuses on ensuring that documentation accurately reflects patient diagnoses, treatments, severity of illness, and risk of mortality while supporting compliance with coding standards, regulatory requirements, and reimbursement guidelines. The CDI Specialist collaborates closely with physicians, clinical staff, coders, and health information management teams to ensure documentation integrity and enhance overall healthcare data quality.</span></p></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px"><u><b>Job Responsibilities 1</b></u></H2> </div><div><p>Conduct concurrent and retrospective reviews of patient medical records to assess the completeness and accuracy of clinical documentation.</p> <p>Ensure documentation accurately reflects the patient’s clinical condition, diagnoses, procedures, and treatment plans.</p> <p>Identify documentation gaps, inconsistencies, or ambiguities that may affect coding accuracy, quality reporting, or reimbursement.</p> <p>Develop and issue physician queries to clarify incomplete, conflicting, or unclear documentation.</p> <p>Ensure queries comply with regulatory guidelines and organizational policies.</p> <p>Facilitate timely physician responses to improve the accuracy and completeness of medical records.</p> <p>Work closely with medical coders to ensure documentation supports accurate ICD coding and case mix index (CMI).</p></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px"><u><b>Job Responsibilities 2</b></u></H2> </div><div><p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Review medical records to ensure diagnoses and procedures are supported by appropriate clinical documentation.</span></p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"> </p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Assist in resolving coding-related documentation issues.</span></p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"> </p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Ensure clinical documentation complies with national and international healthcare regulations, accreditation standards, and organizational policies.</span></p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"> </p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Support compliance with regulatory bodies and accreditation organizations (e.g., JCI, local regulatory authorities).</span></p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"> </p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Monitor documentation practices to reduce compliance risks.</span></p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"> </p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Analyze documentation trends and identify opportunities for improvement.</span></p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"> </p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Track key CDI metrics such as query rates, physician response rates, case mix index (CMI), and documentation accuracy.</span></p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"> </p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Prepare reports and dashboards for leadership and quality improvement initiatives.</span></p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"> </p> <p style="margin-top:0.0in;margin-right:0.0in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Educate physicians and clinical staff on best practices in clinical documentation.</span></p></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px"><b>Additional Responsibilities 3</b></H2> </div><div></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px"><u><b>Job Knowledge & Skills</b></u></H2> </div><div><p style="margin-top:6.0pt;margin-right:0.1in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Analytical and Critical Thinking</span></p> <p style="margin-top:6.0pt;margin-right:0.1in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Attention to Detail</span></p> <p style="margin-top:6.0pt;margin-right:0.1in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Effective Communication and Collaboration</span></p> <p style="margin-top:6.0pt;margin-right:0.1in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Influencing and Education Skills</span></p> <p style="margin-top:6.0pt;margin-right:0.1in;margin-bottom:0.0in;font-size:10.0pt;font-family:'Times New Roman', serif"><span style="font-family:Arial, sans-serif">Problem Solving</span></p> <p><span style="font-size:10.0pt;font-family:Arial, sans-serif">Professional Integrity and Ethical Practice</span></p></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px"><u><b>Job Experience</b></u></H2> </div><div><p><span style="font-size:10.0pt">Minimum 3–5 years of experience in clinical documentation improvement, medical coding, health information management, or clinical practice.</span></p> <p><span style="font-size:10.0pt;font-family:Arial, sans-serif">Experience working with electronic health record systems in a hospital environment</span></p></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px"><u><b>Competencies</b></u></H2> </div><div><div>Agility</div><div>AI Fluency</div><div>Clinical Documentation Improvement L3</div><div>Clinical Information Systems L3</div><div>Electronic Health Record (EHR) Systems L3</div><div>Leadership</div><div>Medical Writing and Communication L3</div><div>Quality</div><div>Regulatory Compliance L3</div><div>Resilience</div></div></div><div style="padding:10.0px 0.0px;border:1.0px solid transparent"><div style="font-size:16.0px;word-wrap:break-word"><H2 style="font-size:1.0em;margin:0.0px"><u><b>Education</b></u></H2> </div><div><div>Bachelor's Degree in Nursing or any related field</div></div></div></div>