Job detail

Clinical Documentation Improvement (CDI) Specialist

Exceptional Healthcare Inc.

#Physicians #RN License #Clinical Documentation #Revenue Cycle #Severity of Illness #CCS #CDIP #CCDS #Physician Queries

Quick overview

The specialist will review inpatient medical records concurrently and retrospectively to find documentation gaps and create compliant, non-leading physician queries to clarify clinical information. They will also educate providers on documentation best practices and monitor key quality and reimbursement metrics.

Requirements summary

Candidates need an Associate or Bachelor's degree in Nursing, HIM, or a related field, along with 3+ years of acute care clinical experience and 2+ years of CDI experience focusing on concurrent review and querying. An active RN license is required if the background is nursing, and relevant certifications are preferred.

associate degreebachelor degreeprofessional certificateRegulatory ComplianceDenial ManagementDRG AssignmentPhysician Querying

Job description

Make your clinical expertise count — beyond the bedside.

We're looking for a CDI Specialist who knows that great patient care starts with great documentation. In this role, you'll partner directly with physicians, nurses, and coders to ensure clinical documentation tells the full story — capturing the true severity of illness, the complexity of care delivered, and the outcomes that matter.

Your work will directly impact reimbursement accuracy, quality scores, and how our hospital's care is reflected to the world.

What You'll Do

Review inpatient medical records concurrently and retrospectively to identify documentation gaps and improvement opportunities
Craft compliant, non-leading physician queries that clarify diagnoses, procedures, and clinical indicators
Educate and coach providers on documentation best practices and regulatory requirements
Monitor key metrics including CMI trends, query response rates, HACs, and PSI indicators
Support denial management with clinical justifications for appealed claims
Collaborate with coding teams to ensure accurate DRG assignment
Develop documentation policies aligned with CIHQ accreditation standards

What You Bring

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
A collaborative approach and the ability to build trust with medical staff

Bonus Points For

CCDS or CDIP certification
Additional coding credentials (CCS, CPC, CIC)

Why This Role?

This isn't a back-office job — you'll be rounding with physicians, shaping how care is captured, and making a measurable impact on quality and revenue. If you love the intersection of clinical knowledge, data, and education, this is your lane.

Reports to: VP of Revenue Cycle