Clinical Documentation Improvement (CDI) Specialist Clinical Documentation Improvement (CDI) Specialist 1 day ago Be among the first 25 applicants This range is provided by SoTalent. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more. Base pay range $74,000.00/yr - $124,000.00/yr Overview: In this role, you will conduct in-depth reviews of inpatient medical records to assess whether clinical documentation accurately conveys the patient's condition and aligns with current healthcare coding and regulatory standards. You'll collaborate with a variety of internal stakeholders—such as coding professionals, case managers, quality teams, and healthcare providers—to support accurate representation of patient acuity and clinical complexity. Key Responsibilities: Perform concurrent documentation assessments for patients currently admitted, ensuring thorough and timely physician notes are present by the time of discharge. Evaluate new daily admissions on designated units, assign preliminary diagnosis-related groups (DRGs), and log information in the appropriate clinical review platform or worksheet. Modify DRG assessments as additional provider documentation or query responses clarify or change patient acuity. Alert team leadership if assigned workload becomes unmanageable or requires redistribution to meet departmental goals. When inconsistencies or gaps in documentation are discovered, initiate structured and compliant clarification queries in accordance with recognized best practices from professional associations. Work to secure prompt and accurate responses to all clinical documentation inquiries sent to physicians or other care providers. Qualifications: Bachelor's degree required. Must hold one of the following professional credentials: Registered Nurse (RN), Doctor of Medicine (MD), or international equivalent (e.g., MBBS). At least 2 years of recent experience in inpatient medical coding or clinical documentation review within a hospital setting. Proficient in DRG logic, ICD coding conventions, and use of encoder tools. Must stay informed on the latest updates to coding regulations and documentation standards. Preferred Experience and Skills: Industry certifications such as CCDS (Certified Clinical Documentation Specialist) or CDIP (Clinical Documentation Improvement Practitioner) are highly desirable. Strong grasp of clinical pathophysiology and the progression of common inpatient diagnoses. Demonstrated ability to apply analytical thinking and exercise sound clinical judgment. Excellent communication skills, especially when clarifying documentation with medical staff in complex or sensitive cases. Comfortable using electronic health records, clinical coding software, and productivity tracking systems. This position is a great fit for healthcare professionals with a keen eye for detail, a passion for improving clinical documentation quality, and a desire to contribute to organizational excellence in health information accuracy and compliance. Seniority level Seniority level Entry level Employment type Employment type Full-time Job function Job function Health Care Provider and Administrative Industries Health and Human Services Referrals increase your chances of interviewing at SoTalent by 2x Sign in to set job alerts for “Documentation Specialist” roles. Corporate Contracts Processor, HVO - $2,000 Sign-On Bonus!** Administrative Assistant and Recruiter, La Jolla Carlsbad, CA $52,000.00-$52,000.00 1 week ago Immigration Law Office - Administrative Assistant Administrative Assistant $18.00 to $19.50/hr. We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI. #J-18808-Ljbffr SoTalent
...Proficiency in Microsoft Office and Google Workspace. Familiarity with file-sharing and e-signature platforms (e.g. ShareFile, Dropbox, Docusign). Strong organizational skills and attention to detail. Clear and professional written and verbal communication....
...Description Description: Do you want to share your passion for healthcare? Are you looking for your next challenge? Join us in partnering... ...new team members. Our team has a wide range of experience levels and tenures. We are focused on building an environment that supports...
...of all ages Experienced in engaging and interacting with diverse families and responsible for coordinating and executing family/adult activities Facilitates programs, parties, movie screenings and arts and crafts for families Support and assist in Community Hall...
...COURT REPORTER II - 22010654 Date: Aug 1, 2025 The State Personnel System is an E-Verify employer. For more information... ...Act. This Organization Participates in E-Verify: Federal law requires all employers to verify the identity and employment...
...About the role: As our Customs Entry Writer, you will be instrumental in the growth and development of the Customs Brokerage business of TQL Global. You will be responsible for filing and maintaining all documentation required by US Customs and Participating Government...