CDI Specialist - Primary Care

Duties and Responsibilities:

• Clinical documentation review: Conduct 100% systematic reviews of outpatient clinic medical records to ensure documentation is specific, complete, and compliant with coding guidelines and regulatory standards.
• Provider collaboration: Interact with physicians and other clinicians to clarify conflicting, imprecise, or incomplete documentation through written queries or verbal communication.
• Education and training: Educate providers on proper documentation techniques and the impact of documentation on Hierarchical Condition Categories (HCCs), coding accuracy, and quality metrics.
• Coding and compliance: Apply knowledge of coding guidelines (e.g., ICD-10, CPT) and reimbursement methodologies (e.g., HCCs) to assess if documentation supports the services billed.
• Data analysis: Track and analyze key CDI data, such as query rates and documentation trends, to identify opportunities for process improvement and targeted education.
• Audit support: Assist with internal and external audits by providing clinical expertise and supporting documentation for claim reviews.
• Quality improvement: Work with interdepartmental teams, such as quality and case management, to improve documentation related to core measures and other patient safety indicators. 

Qualifications:

• Education: Associate or bachelor's degree in nursing (RN) or Health Information Management (RHIA/RHIT) is required.
• Certification: Relevant professional certifications such as Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), or Certified Coding Specialist (CCS) are highly preferred.
• Experience: A minimum of 2–3 years of recent clinical experience in an outpatient or acute care setting is typically required. Experience in coding, utilization review, or case management is also beneficial.

Skills and abilities:

• Strong clinical knowledge and understanding of disease processes.
• Excellent written and verbal communication and interpersonal skills.
• Exceptional critical thinking and analytical abilities.
• Proficiency with electronic health records (EHR) and other CDI software.
• Ability to work independently and manage time effectively.