Job Description

Job Description

Job Description

Clinical Document Improvement Specialist – Hybrid Opportunity

We are seeking a skilled and detail-oriented Clinical Document Improvement Specialist to join a high-performing CDI department. This full-time, hybrid position runs Monday through Friday, 8:00 AM to 4:30 PM PT. The Clinical Document Improvement Specialist will be responsible for conducting concurrent reviews, querying clinical staff, and supporting accurate clinical documentation to reflect severity of illness, risk of mortality, and quality metrics.

Job Responsibilities – Clinical Document Improvement Specialist

• Perform concurrent reviews on inpatient admissions with a daily caseload of approximately 25 cases.

• Ensure clinical documentation supports CC/MCC capture, SOI/ROM, and other organizational quality initiatives.

• Meet or exceed minimum productivity targets (25 reviews/day, 25% query rate).

• Communicate with physicians and clinical teams to clarify documentation through compliant queries.

• Review cases spanning multiple service lines including general surgery, trauma, orthopedic, spinal fusion, and bedside procedures.

• Collaborate with CDI team to identify trends and documentation improvement opportunities.

• Maintain up-to-date knowledge of coding, DRG methodology, and quality reporting metrics.

Required Qualifications – Clinical Document Improvement Specialist

• Minimum 3 years of experience as a Clinical Document Improvement Specialist.

• Licensed Registered Nurse (RN) in any U.S. state or Foreign Medical Graduate (e.g., MD, MBBS, MBChB).

• Certified Clinical Documentation Specialist (CCDS) credential.

• Strong understanding of inpatient CDI practices and documentation standards.

• Proficient in conducting concurrent reviews and generating compliant provider queries.

• Comfortable working in a hybrid environment with onsite and remote responsibilities.

Preferred Qualifications

• 5 or more years of experience in Clinical Documentation Improvement.

• DRG audit or reconciliation experience.

• Familiarity with quality metrics such as SOI/ROM and mortality tracking.

• Experience with multiple hospital sites or systems.

This is an excellent opportunity for an experienced Clinical Document Improvement Specialist who is passionate about quality care, accurate documentation, and collaborative provider engagement. The ideal Clinical Document Improvement Specialist will be results-driven, inquisitive, and committed to documentation excellence.

Clinical Documentation Specialist, CDI Nurse, Documentation Integrity Specialist, DRG Validation Specialist, Medical Documentation Reviewer, Concurrent Review Nurse, Clinical Quality Reviewer, Clinical Chart Auditor, Health Information Integrity Specialist, CDI Consultant

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