CDI Specialist

Required Skills & Experience

Required Qualifications:

-Licensure: Active RN required. If they don’t have their BSN they need to obtain it within 5 years -Experience: Minimum of 5 years clinical experience in trauma, ICU, Med Surg, or ED and 3 years CDI, preferably academic medical center, community hospital and/or Level 1 Trauma experience. -Certifications: CCDS (Certified Clinical Documentation Specialist) or CDIP (Clinical Documentation Improvement Practitioner) preferred. -Skills: Strong understanding of ICD-10-CM, DRG assignment, and clinical coding guidelines. Ability to discuss complex medical diagnoses and treatment plans.

Job Description

Insight Global is seeking a Clinical documentation information specialist for a large health system in Virginia. A CDI Specialist is responsible for improving the quality, accuracy, and completeness of clinical documentation in healthcare settings. This role ensures that medical records accurately reflect the patient’s clinical status, which supports appropriate coding, billing, and quality reporting.

Job duties include:

-Documentation Review: Analyze records to ensure documentation supports accurate diagnosis coding and reflects the severity of illness and risk of mortality. -Provider Engagement: Collaborate with physicians, residents, and mid-level providers to clarify documentation through queries and education. -Interdepartmental Coordination: Work closely with coding, case management, and quality teams to align documentation with coding and billing standards. -Education & Training: Provide ongoing education to clinical staff on documentation best practices and regulatory requirements. -Compliance & Quality Metrics: Ensure documentation supports compliance with CMS, Joint Commission, and other regulatory bodies. Track and report CDI metrics to leadership.