Job Role Description

Medical/Healthcare > Clinical Documentation Improvement (CDI) Specialist

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Short Description:

A Clinical Documentation Improvement (CDI) Specialist is responsible for reviewing patient medical records to ensure accurate, complete, and compliant clinical documentation. They work closely with healthcare providers to clarify diagnoses, procedures, and patient care details, supporting proper coding and reimbursement. The role involves analyzing documentation trends, educating clinical staff, and maintaining adherence to regulatory and quality standards. CDI Specialists help improve the accuracy of patient records, optimize revenue cycle performance, and enhance quality of care reporting. Strong clinical knowledge, attention to detail, and communication skills are essential for success in this role.

Duties / Responsibilities:

  • Review patient medical records to ensure accurate, complete, and compliant clinical documentation
  • Collaborate with physicians, nurses, and other healthcare providers to clarify documentation and ensure all diagnoses, procedures, and comorbidities are properly captured
  • Analyze clinical data to identify gaps, inconsistencies, or opportunities for documentation improvement
  • Educate clinical staff on documentation best practices, coding requirements, and regulatory standards
  • Support coding and billing teams by providing detailed clinical clarifications to optimize accurate reimbursement
  • Monitor key performance indicators (KPIs) related to documentation quality, coding accuracy, and compliance
  • Participate in audits and quality assurance initiatives to maintain regulatory and accreditation standards
  • Develop and maintain CDI policies, procedures, and workflow guidelines for the organization
  • Stay updated on industry guidelines, coding standards (ICD-10, CPT), and healthcare regulations impacting documentation
  • Provide feedback and recommendations to clinical leadership for ongoing improvement in documentation processes

Skills / Requirements / Qualifications

  • Education: Bachelor’s degree in nursing, health information management, or related healthcare field required
  • Experience: 2–4 years of clinical experience in acute care, coding, or health information management preferred
  • Clinical Knowledge: Strong understanding of medical terminology, disease processes, and healthcare documentation requirements
  • Analytical Skills: Ability to identify documentation gaps and interpret complex clinical information
  • Communication: Effective verbal and written communication skills for interacting with physicians, nurses, and coding staff
  • Regulatory Knowledge: Familiarity with ICD-10, CPT coding, and healthcare compliance standards
  • Attention to Detail: Precision in reviewing records and ensuring accurate, compliant documentation
  • Problem-Solving: Ability to recommend improvements and resolve documentation discrepancies efficiently

Job Zones

  • Title: Job Zone Four: Considerable Preparation Needed
  • Education: Most of these occupations require a four-year bachelor's degree, but some do not. 
  • Related Experience: A considerable amount of work-related skill, knowledge, or experience is needed for these occupations. 
  • Job Training: Employees in these occupations usually need several years of work-related experience, on-the-job training, and/or vocational training.
  • Job Zone Examples: Many of these occupations involve coordinating, supervising, managing, or training others. 
  • Specific Vocational Preparation in years: 2-4 years preparation (7.0 to < 8.0)

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