CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST JOB DESCRIPTION

A Clinical Documentation Improvement Specialist works concurrently alongside the inpatient care team, reviewing records while patients are still in house and issuing compliant queries under ACDIS guidelines before discharge closes the window. This role sits at the intersection of clinical judgment and coding governance, answering to both the CDI department and the physicians whose documentation it shapes. Getting the MS-DRG and APR-DRG assignments right the first time is the measure of the work.

As the Clinical Documentation Improvement Specialist, you will conduct concurrent and retrospective reviews of inpatient medical records to ensure that severity of illness, risk of mortality, and DRG assignment accurately reflect each patient's clinical complexity and support compliant reimbursement. Working within the CDI department alongside coding staff, quality teams, and attending physicians, you will own the query process from initiation through resolution across an acute care facility.

Career Impact: Mastery of ICD-10-CM, MS-DRG structure, and ACDIS query standards positions CDI professionals as sought-after experts that hospitals, health systems, and payers actively compete to hire.

Business Impact: Accurate DRG assignment and complete capture of co-morbid conditions directly protect facility reimbursement and case mix index from payer denial and underpayment.

Growth Opportunity: CDI specialists who develop deep proficiency in clinical validation and denial management commonly advance into CDI Manager, Coding Director, or Revenue Integrity leadership roles.

• Conduct concurrent inpatient chart reviews for assigned patients, initiating follow-up reviews every two to three days through discharge.
• Formulate working DRG assignments by identifying diagnoses and procedure codes that reflect documented clinical complexity.
• Compose and transmit compliant provider queries in accordance with ACDIS guidelines to clarify principal diagnosis, co-morbid conditions, and procedures.
• Collaborate with coding staff to reconcile DRG mismatches and confirm that final MS-DRG and APR-DRG assignments are supported by complete documentation.
• Educate physicians and clinical staff on ICD-10-CM coding guidelines and documentation standards to improve specificity and completeness.
• Monitor severity of illness, risk of mortality, present-on-admission indicators, and patient safety measures to ensure each is clearly captured in the medical record.
• Validate inpatient diagnoses through clinical review, engaging physician advisors to support appeal of RAC and third-party payer denials when documentation is challenged.
• Collect and report data on query activity, DRG distribution, and case mix index movement to CDI leadership.

• Associate's degree in Nursing, Health Information Management, or a related field, or equivalent work experience.
• 3 or more years of acute care clinical or inpatient CDI experience, with direct involvement in concurrent chart review and physician query processes.
• Active RN license in good standing, or RHIA/RHIT credential with inpatient CDI experience in an acute care setting.
• One of the following certifications required: CCDS, CDIP, CDEI, CCS, or RHIT with demonstrated CDI competency.
• Proficiency in ICD-10-CM and PCS Official Guidelines for Coding and Reporting, including CC/MCC capture and MS-DRG structure.
• Knowledge of CMS reimbursement methodology, including Medicare MS-DRG and Medicaid APR-DRG classification systems.
• Strong clinical knowledge of disease processes, pathophysiology, anatomy and physiology, and pharmacology as applied to documentation review.
• Demonstrated ability to communicate effectively with attending physicians, nursing staff, and coding auditors in a fast-moving inpatient environment.

• Experience managing RAC, third-party payer, or ALJ-level denial appeals, including preparation of clinical validation arguments.
• Familiarity with AHA Coding Clinic guidance and its application to complex inpatient coding scenarios.
• Prior experience in a teaching hospital, academic medical center, or level 1 trauma facility with high case complexity.
• Knowledge of quality-based reporting programs, including present-on-admission indicators and patient safety indicators as they relate to DRG assignment.

• Query response rate, measuring physician engagement with documentation clarification requests as a percentage of queries issued.
• DRG agreement rate between working DRG assigned by the CDIS and final DRG assigned by coding staff.
• Case mix index movement, reflecting the net change in facility CMI attributable to CDI query activity over a defined period.
• Denial overturn rate on RAC and third-party payer appeals supported by clinical validation documentation.
• CC/MCC capture rate, measuring the proportion of eligible admissions where a complication or comorbidity is documented and coded.

• Base Salary Range: $70,000 to $95,000 annually, depending on experience and facility size.
• Bonus: Annual performance bonus of 3 to 7 percent, tied to CDI productivity metrics.
• Equity: Not typical at this level in hospital settings.
• Health Benefits: Medical, dental, and vision coverage; employer contribution standard.
• PTO: 15 to 22 days annually, plus observed holidays.
• Common Perks: Continuing education reimbursement, certification renewal support, hybrid or remote flexibility for retrospective review work.

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Background checks, including criminal history and applicable drug screening, are a standard condition of employment in acute care settings and will be completed prior to start date. All qualified applicants are considered without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected under federal, state, or local law. Reasonable accommodations are available to individuals with disabilities throughout the application and employment process. Candidates must be authorized to work in the United States.

The Clinical Documentation Improvement Specialist owns the review and analysis of health records to identify relevant diagnoses and procedures, supporting accurate reimbursement and regulatory compliance across Federal and State prospective payment requirements. Reporting to HIM leadership, this specialist works with physicians and clinical staff to strengthen coding accuracy and documentation quality across patient encounters and payer submissions.

Key Responsibilities

• Review and analyze health records to identify relevant diagnoses and procedures for distinct patient encounters.
• Research billed unlisted procedure codes to determine if a more specific code exists and should be used.
• Communicate with physicians to clarify diagnoses, procedures, coding, and documentation requirements.
• Translate diagnostic phrases utilized by healthcare providers into coded form.
• Help clinicians on appropriate use of ICD-10 codes to maximize HEDIS performance incentives submitted through claims data.
• Monitor all coding accuracy at various levels of detail and maintain coding quality as needed.
• Track coding issues and review coding inaccuracies to highlight areas of improvement.
• Report, resolve, or escalate issues as necessary.
• Perform a comprehensive medical records review to assure the presence of all components required to support information submitted to payers.
• Provide a high level of technical proficiency and serve as subject matter specialist regarding coding and documentation.
• Review payment denials, underpayments, and payment take backs for appropriateness and produce resolution by adjustments.
• Participate actively in the Quality Management Program.
• Follow all agency safety and health standards, regulations, procedures, policies, and practices.
• Participate actively in the Management of the Environment of Care Program.

Required Qualifications

• Minimum A.S. Degree in the healthcare field, preferably in Health Information Technology from an accredited college.
• One of the following certifications required RHIA, RHIT, CCS, CDIP, or CPC.
• Strong understanding and knowledge of state, federal, and accreditation regulatory requirements including HIPAA Privacy, CMIA, and Managed Health Care Plans.
• Knowledge of information systems and healthcare applications.
• Effective organizational, communication, and customer service skills.
• Ability to utilize information systems effectively including Microsoft Office and Outlook.
• Ability to demonstrate credibility with physicians and maintain productive and collaborative relationships with all clinical staff.
• Comfortable educating clinicians.
• Strong problem solving, group facilitation, and teamwork skills.
• Ability to maintain patient confidentiality.
• Ability to work well with others in a team-oriented environment and independently when needed.

Embedded within the HIM, Quality, and Service Line departments, the Clinical Documentation Improvement Specialist delivers concurrent inpatient chart reviews to ensure documentation accuracy that supports appropriate reimbursement, severity of illness, risk of mortality, and quality measures. Working closely with physicians, clinicians, and coding teams, this specialist shapes timely and complete medical record documentation across all designated payers and publicly reported quality metrics.

Core Functions

• Interact with Clinical Coding Specialists and Second Level Reviewers to establish a strong, collaborative relationship with the coding team.
• Facilitate physician queries and assist in obtaining clinically complete and specific documentation needed for compliant coding.
• Assure any clarification is documented appropriately in the patient's record according to policy.
• Follow up with physician when appropriate.
• Improve accuracy, documentation specificity, and completeness through real-time interactive communication with physicians, clinicians, and other involved parties.
• Work daily with physicians to improve documentation capture of diagnosis specificity, all secondary diagnoses, and procedures during the patient stay.
• Deploy queries, face-to-face communications, and educational programs using clinical knowledge to achieve documentation goals.
• Abide by all documentation and coding conventions, ethical and professional standards, and rules established by CMS and AHIMA.
• Adhere to AHIMA query guidelines.
• Remain current with coding and documentation improvement techniques to support accuracy of codes and the resulting working DRG.
• Participate in educational programs and in-services to maintain and exceed excellence in documentation and coding skills.
• Participate in the peer review process as both a reviewer and reviewee as a means of education and feedback.

Qualifications & Experience

• Bachelor's Degree in Nursing.
• RN license required.
• Minimum 5 years of experience as an RN.
• Strong clinical skills including understanding of clinical disease processes, pathophysiology, and treatment plans.
• Working knowledge of regulatory coding guidelines preferred.
• Proficient with MS Office applications.
• Effective interpersonal skills to interact with physicians and all levels of hospital personnel.
• Strong organization and prioritization skills.
• Effective written and verbal communication skills.
• Fluent English in reading, writing, and speaking.

Reporting to CDI and coding leadership, the Clinical Documentation Improvement Specialist leads prospective and retrospective medical record reviews to ensure documentation accuracy that supports appropriate reimbursement and patient risk scores. Partnering with interdisciplinary teams, coding education staff, and health plan partners, this specialist advances regulatory compliance and optimum reimbursement outcomes across Risk Adjustment Payment System requirements.

Primary Duties

• Conduct prospective and retrospective review of the medical record to ensure accurate, complete, and specific documentation reflecting the current clinical complexity of the patient.
• Collaborate with Coding and Coding Education Staff to provide education to providers and support clinical care teams on documentation, coding changes, and compliance concerns.
• Monitor changes in laws, regulations, rules, and code assignments that impact documentation, reimbursement, and patient risk scores.
• Provide input and valuable feedback on audit results as applicable.
• Collaborate with interdisciplinary teams to assist with problem resolution, appropriate reimbursement, and systems and performance measures.
• Provide consultation and education to organizational departments and committees as requested to ensure regulatory compliance and optimum reimbursement.
• Develop relationships with providers and communicate guidelines and requirements of the Risk Adjustment Payment System to ensure accurate coding and documentation.
• Complete and track all Patient Assessment Forms and other various projects as requested by health plans.

Skills & Qualifications

• Associate's degree in Nursing or higher required; Bachelor's Degree in Nursing preferred.
• Current RN license in good standing required.
• Certified Risk Adjustment Coder (CRC) or ability to obtain certification within 6 months from date of hire.
• Minimum 5 years of recent clinical experience, preferably in a primary care setting.
• 1+ years of recent ICD-10 coding experience and/or 1+ years of recent Risk Adjustment or HCC Coding experience preferred.
• Knowledge of HEDIS, abstraction concepts, Medicare Risk Adjustment, and CMS risk adjustment guidelines preferred.
• Knowledge of health plan terminology and concepts preferred.
• Knowledge of related regulations and requirements supporting ACA and Commercial Risk Adjustment Data Validation.
• Proficient with Microsoft Office products including Word, Outlook, Excel, and PowerPoint.
• Experience with EMR, preferably eClinical Works.
• Strong attention to detail, organizational, and prioritization skills.
• Ability to handle multiple tasks simultaneously.
• Excellent oral and written communication skills with professional judgment and decision-making ability.
• Strong problem solving and deductive reasoning skills.

Sitting at the intersection of clinical documentation and revenue cycle management, the Clinical Documentation Improvement Specialist shapes the full lifecycle of RAC and Third Party Payor denial appeals while conducting clinical validation for inpatient diagnoses that impact DRG assignment and payment. Operating across HIM, CDI leadership, coding staff, and physician advisors, this specialist builds documentation improvement programs and prepares cases through ALJ and DRA hearing levels.

Duties

• Initiate and follow through on all RAC and Third Party Payor denials at every level.
• Review all denials with direct report for plan and strategy for appeal.
• Involve appropriate physicians in the appeal process and prepare for ALJ and DRA hearings.
• Follow up on Third Party Payor responses to all appeals as appropriate.
• Update RAC and Third Party Payor focus studies and revenue cycle records with attention to detail.
• Communicate denial issues with site HIM and CDIP Department and patient accounts.
• Continuously evaluate the quality of clinical documentation to identify incomplete or inconsistent documentation.
• Conduct clinical validation for inpatient diagnoses that impact code selection, resulting DRG, and payment.
• Communicate with physician advisor or attending physician verbally or through written methodology to validate diagnosis in question and support appeal.
• Provide feedback to HIM management staff and CDI leadership regarding opportunities for documentation improvement.
• Participate in the planning and development of educational programs directed toward improving documentation.
• Participate in education programs to maintain up-to-date coding skills.

Experience & Qualifications

• Bachelor of Science in Nursing.
• Current NYS RN License.
• CCDS certification required.
• Five years of clinical experience in an acute hospital setting.
• Minimum 2 years of inpatient CDI experience.
• Working knowledge of AHA Coding Clinics.
• Proficiency in ICD-10-CM and PCS Official Guidelines for Coding and Reporting.
• Working knowledge of encoder and ability to correct coding and re-drop bill.
• Proficient computer skills in Windows Microsoft Office Applications including Word, Excel, and PowerPoint.
• Self-motivated, self-directed, and able to work independently with minimal supervision.
• Strong multitasking, communication, and critical thinking skills.

A key member of the CDI and coding team, the Clinical Documentation Improvement Specialist builds concurrent and retrospective review workflows that maintain query benchmarks and support accurate MS-DRG, APR-DRG, SOI, and ROM assignment. Collaborating across providers and Coding Auditors, this specialist ensures complete data entry into CDI applications to enable final code assignment at a major academic medical center or level 1 trauma facility.

Accountabilities

• Conduct initial and follow-up concurrent reviews of medical records for assigned patients.
• Maintain query rate, response rate, and agreement rate in line with established benchmarks.
• Maintain competency in use of CDI applications.
• Enter all required data into CDI applications to enable Coders and Coding Auditors to assign final MS-DRG, APR-DRG, SOI, and ROM.
• Interact with providers and Coding Auditors.
• Assist with retrospective queries as needed.

Requirements

• Possesses strong clinical skills and knowledge.
• Experience with a major academic medical center, teaching facility, and/or level 1 trauma facility.
• Excellent verbal and written communication skills.
• Strong interpersonal skills, particularly in working with physicians, nurses, and coding auditors.
• Proficient with use of various computer applications.
• Ability to quickly learn new systems.

Accurate reimbursement, quality outcomes, and patient safety measures depend on the Clinical Documentation Improvement Specialist, who performs concurrent inpatient chart reviews to identify documentation improvement opportunities and assign working DRGs using CDI software. Based within a cross-functional environment spanning coding, medical staff, quality, utilization review, and risk management, this specialist delivers compliant provider queries in line with ACDIS guidelines and builds a culture of documentation improvement across the organization.

Key Deliverables

• Complete daily concurrent reviews of the medical record to identify opportunities for clarification or improvement of clinical documentation.
• Identify diagnoses and procedure codes to assign an accurate working DRG.
• Perform follow-up medical record reviews to identify additional diagnoses or procedures that may impact the DRG assignment.
• Create and send compliant provider queries in accordance with ACDIS guidelines.
• Carry out follow-up practices related to provider query responses per department policy.
• Confer with coders to ensure appropriate final DRG and completeness of supporting documentation.
• Coordinate with coding to reconcile DRG mismatches.
• Collect and report on data showing activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.
• Ensure quality, patient safety indicators, present on admission indicators, risk of mortality, and severity of illness measures are clearly and accurately documented in the medical record.
• Partner effectively with stakeholders across the system including medical staff, quality, utilization review, and risk management.
• Adhere to ACDIS Code of Ethics, HIPAA, and official coding guidelines.
• Train other staff as directed and fulfill all organizational requirements.
• Comply with and maintain knowledge of all relevant laws, regulations, policies, procedures, and standards.
• Foster a culture of improvement, efficiency, and innovative thinking.
• Provide a remote workspace compliant with HIPAA guidelines.

Education & Experience

• Associate's degree or higher in Nursing or Health Information Management or related field, or equivalent experience.
• Bachelor's degree or higher in Nursing or HIM or related field or equivalent experience preferred.
• One of the following certifications required RHIA, RHIT, CCS, CPC, RN, CDIS, CDIP, CDEI, or CCDS.
• One of the following preferred CDIS, CDIP, CDEI, or CCDS.
• Minimum 2 years of acute or inpatient experience as an RN, or 2 years of inpatient coding or CDI experience.
• 5 years of acute or inpatient care nursing or 5 years of inpatient coding or CDI experience preferred.
• Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations.
• Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, and ancillary test results.
• Knowledge of ICD-10-CM and DRG classification systems.
• Knowledge of physician and nursing unit practices.
• Proficiency in Microsoft products including Teams, Word, Excel, and Outlook, as well as EPIC and other assigned programs.
• Excellent interpersonal, analytical, critical thinking, problem solving, and conflict management skills.
• Excellent verbal and written communication skills.
• Ability to work independently, self-motivate, and adapt to change.
• Strong attention to detail to achieve thoroughness and accuracy when accomplishing a task.

As the Clinical Documentation Improvement Specialist, this role leads medical chart reviews and provider education to ensure ICD-10-CM coding accuracy and compliant documentation in support of Devoted's Quality and Risk Adjustment strategy. The CDI team relies on this work to advance organizational coding quality goals, improve documentation trends, and maintain current alignment with CMS Risk Adjustment guidance and AHA Coding Clinic updates.

Scope of Work

• Perform medical record reviews based on organizational priorities including both concurrent CDI workflows and retrospective reviews.
• Create presentations and communicate with providers, provider staff, and vendors regarding documentation trends and areas of opportunity for compliant coding practices.
• Encourage and guide providers and provider staff to use CDI resources such as one-pagers and tip sheets.
• Assist CDI Manager by making recommendations for process improvements to further enhance coding quality goals and outcomes.
• Handle other related duties as required or assigned including provider education, training, and working with vendor partners.
• Remain current on ICD-10-CM coding guidelines, AHA Coding Clinic Guidance, and CMS Risk Adjustment guidance.

Technical Qualifications

• CPC or CRC certification through AAPC, or CDI or CCS certification through AHIMA required.
• 3+ years as an outpatient CDI specialist, or 5+ years in risk adjustment coding and auditing.
• Prior CPT coding or clinical experience is a plus.
• Strong analytical and problem solving skills.
• Strong oral and written communication skills.
• Strong organization and time management skills.
• Ability to work independently and manage multiple tasks simultaneously.

Clinical Documentation Improvement Specialist conducts thorough chart reviews and composes compliant queries under CMS and AHIMA guidelines to clarify principal diagnoses, co-morbid conditions, and procedures within acute care medical records. The work directly supports coding staff accuracy and regulatory compliance across Medicare MSDRG, Medicaid APRDRG, and third-party payer reimbursement methodologies in a hybrid office and remote environment.

Day-to-Day Responsibilities

• Perform thorough, methodical chart reviews according to department review process.
• Comprehensively review all physician and clinical documentation to identify potential opportunities for documentation improvement.
• Compose clinical documentation queries that are compliant with CMS and AHIMA guidelines.
• Communicate effectively with physicians and other members of the interdisciplinary team to establish appropriate levels of severity of illness and risk of mortality.
• Clarify accurate documentation of principal diagnosis, co-morbid conditions, complications, and procedures in the medical record.
• Assist in developing educational tools for clinical and non-clinical staff.
• Collaborate with the coding staff to ensure accuracy of documentation and coding in compliance with state and federal requirements and standards.
• Work both in office and remotely as a hybrid position.

Background & Experience

• Registered Professional Nurse with Bachelor of Science in Nursing preferred.
• Bachelor's Degree with minimum 4 years of acute care clinical experience preferred.
• Licensed Nurse Practitioner or Physician's Assistant with acute care clinical experience accepted.
• MD with ECFMG qualification or equivalent accepted.
• RHIA or RHIT with CDI and inpatient coding experience in an acute care setting accepted.
• Minimum 4 years of acute care or inpatient experience, preferably critical care.
• Advanced broad-based clinical expertise and extensive knowledge of complex disease processes, anatomy and physiology, and medical and surgical procedures required.
• Knowledge of ICD-10-CM and PCS coding guidelines.
• Knowledge of reimbursement methodology including Medicare MSDRG, Medicaid APRDRG, and third-party payers.
• Familiarity with ICD-10-CM and PCS coding system and DRG assignment.

The Clinical Documentation Improvement Specialist owns concurrent medical record facilitation to ensure accurate ICD-10 code and DRG assignment by identifying co-morbid conditions, complications, and causal agents across an acute care setting. Reporting to CDI leadership, this specialist collaborates with medical, nursing, ancillary, and coding staff to deliver documentation clarity that accurately reflects severity of illness and risk of mortality.

Areas of Ownership

• Ensure clinical documentation is accurate, compliant, and specific to reflect the severity of illness and risk of mortality of the patient.
• Facilitate concurrent documentation of the medical record to realize accurate and complete representation of severity of illness and risk of mortality, resulting in the appropriate ICD-10 code and DRG assignment.
• Work collaboratively with medical, nursing, ancillary, and coding staff to improve the quality of chart documentation.
• Identify complications and co-morbid conditions, specify co-existing conditions and causal agents, and follow up with responsible physicians for appropriate documentation.
• Identify the need to clarify documentation in the medical record and communicate with physicians face-to-face or using appropriate query tools.
• Stay abreast of coding guidelines, reimbursement methodologies, regulatory compliance, and quality-based programs.
• Serve as a resource and educate physicians on linking coding guidelines and medical terminology to capture accurate final code assignment.

Minimum Qualifications

• Associate's degree in Nursing required; Bachelor's degree in Nursing preferred.
• Active RN license in good standing required.
• CDIP or CCDS certification preferred.
• Minimum 3 years of nursing experience in an acute care setting, or 1 or more years of experience as a Clinical Documentation Specialist in an acute care setting required.
• CDI experience preferred.
• Knowledge of clinical care and treatment options to critically assess appropriateness of documentation.
• Clinical knowledge of disease processes, pathophysiology, and pharmacology.

Embedded within the VAMHCS clinical services environment, the Clinical Documentation Improvement Specialist delivers comprehensive analysis of clinical documentation practices to identify deficiencies and produce actionable improvement recommendations across provider interviews, coding data analysis, and documentation reviews. Working closely with physicians, nursing staff, ancillary departments, and coding teams, this specialist builds the accuracy of severity of illness, risk of mortality, final code assignment, and case mix index in alignment with VHA Handbook and CMS regulatory requirements.

Job Fnctions

• Analyze documentation of the clinical status of patients, current treatment plan, and past medical history.
• Identify potential gaps in provider documentation.
• Educate physicians and healthcare providers regarding clinical documentation improvements and need for accuracy in health record documentation.
• Collaborate with physicians, nursing staff, ancillary departments, and coding staff to ensure that clinical documentation is compliant, complete, and accurate.
• Collaborate with coding staff to ensure documentation is a complete reflection of the care received, as well as the patient's clinical status, acuity, severity of illness, and risk of mortality.
• Serve as a resource to providers to help link coding guidelines and medical terminology to improve accuracy of the patient's severity of illness, risk of mortality, final code assignment, and case mix index.
• Implement government-approved metrics to track the success of the Clinical Documentation Improvement program.

Professional Experience

• Bachelor's degree in health information management, nursing, or equivalent with 5 years of relevant experience, or 6 additional years of related experience in lieu of degree.
• Currently licensed as a Registered Nurse or other relevant licensed independent practitioner.
• Certified Clinical Documentation Specialist (CCDS) and/or Clinical Documentation Improvement Practitioner (CDIP) required.
• Clinical knowledge of anatomy and physiology, pathophysiology, and pharmacology.
• Knowledge of VHA Handbook 1907.01, VHA Handbook 1907.03, VHA Coding Guidelines, and Medical Staff Bylaws.
• Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Knowledge of healthcare regulations defining documentation requirements including guidelines from regulatory bodies such as CMS.
• Knowledge of coding rules and requirements including clinical classification systems, CC/MCC, MS-DRG structure, and POA indicators.
• Knowledge of severity of illness and risk of mortality indicators.
• Knowledge of documentation impact on reimbursement including third-party payer requirements.
• Ability to interpret and analyze all information in a patient's health record to identify opportunities for more precise and complete documentation.
• Ability to establish and maintain strong verbal and written communication with providers.