Clinical Documentation Improvement Specialist
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Key skills for this role
About the Role
UrbaCon Contracting & Trading Company is seeking a Clinical Documentation Improvement (CDI) Specialist to improve the quality and accuracy of clinical documentation in patient medical records.
Key Skills for This Role
Responsibilities
- Conduct concurrent and retrospective reviews of patient medical records to assess completeness and accuracy of clinical documentation
- Ensure documentation accurately reflects patient's clinical condition, diagnoses, procedures, and treatment plans
- Identify documentation gaps, inconsistencies, or ambiguities affecting coding accuracy or reimbursement
- Develop and issue physician queries to clarify incomplete or unclear documentation
- Collaborate with medical coders to ensure documentation supports accurate ICD coding and case mix index
- Ensure compliance with national and international healthcare regulations and accreditation standards
- Analyze documentation trends and track key CDI metrics
- Educate physicians and clinical staff on best practices in clinical documentation
Requirements
- Minimum 3 5 years of experience in clinical documentation improvement, medical coding, health information management, or clinical practice
- Experience working with electronic health record systems in a hospital environment
- Bachelor's Degree in Nursing or any related field
- Strong analytical and critical thinking skills
- Effective communication and collaboration skills
Full Job Posting
Job Summary
- 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 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.
Job Responsibilities 1
- Conduct concurrent and retrospective reviews of patient medical records to assess the completeness and accuracy of clinical documentation.
- Ensure documentation accurately reflects the patient’s clinical condition, diagnoses, procedures, and treatment plans.
- Identify documentation gaps, inconsistencies, or ambiguities that may affect coding accuracy, quality reporting, or reimbursement.
- Develop and issue physician queries to clarify incomplete, conflicting, or unclear documentation.
- Ensure queries comply with regulatory guidelines and organizational policies.
- Facilitate timely physician responses to improve the accuracy and completeness of medical records.
- Work closely with medical coders to ensure documentation supports accurate ICD coding and case mix index (CMI).
Job Responsibilities 2
- Review medical records to ensure diagnoses and procedures are supported by appropriate clinical documentation.
- Assist in resolving coding related documentation issues.
- Ensure clinical documentation complies with national and international healthcare regulations, accreditation standards, and organizational policies.
- Support compliance with regulatory bodies and accreditation organizations (e.g., JCI, local regulatory authorities).
- Monitor documentation practices to reduce compliance risks.
- Analyze documentation trends and identify opportunities for improvement.
- Track key CDI metrics such as query rates, physician response rates, case mix index (CMI), and documentation accuracy.
- Prepare reports and dashboards for leadership and quality improvement initiatives.
- Educate physicians and clinical staff on best practices in clinical documentation.
Job Knowledge & Skills
- Analytical and Critical Thinking
- Attention to Detail
- Effective Communication and Collaboration
- Influencing and Education Skills
- Problem Solving
- Professional Integrity and Ethical Practice
Job Experience
- Minimum 3–5 years of experience in clinical documentation improvement, medical coding, health information management, or clinical practice.
- Experience working with electronic health record systems in a hospital environment
Competencies
- Agility
- AI Fluency
- Clinical Documentation Improvement L3
- Clinical Information Systems L3
- Electronic Health Record (EHR) Systems L3
- Leadership
- Medical Writing and Communication L3
- Quality
- Regulatory Compliance L3
- Resilience
Education
- Bachelor's Degree in Nursing or any related field
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