Analyst & SME_CDI_EM

Job Title:

Position Summary:

The Clinical Documentation Improvement (CDI) Specialist is responsible for improving the quality, accuracy, and completeness of clinical documentation in the patient medical record. This role ensures that documentation accurately reflects the patients clinical status, supports appropriate coding, and meets regulatory and compliance standards. The CDI Specialist works collaboratively with physicians, nurses, coding staff, and other healthcare professionals to optimize documentation practices and enhance patient care and reimbursement.

Key Responsibilities:

• Review clinical documentation for completeness, clarity, and accuracy to ensure it reflects the full scope of patient care.
• Identify gaps or inconsistencies in documentation and communicate with healthcare providers to clarify and improve clinical records.
• Collaborate with physicians, nurses, and coding professionals to ensure accurate and timely documentation for inpatient and outpatient encounters.
• Educate clinical staff on documentation best practices, coding guidelines, and regulatory requirements.
• Monitor documentation trends and provide feedback to improve overall compliance and quality.
• Support coding accuracy to ensure proper billing and reimbursement in accordance with ICD, CPT, and other relevant coding standards.
• Participate in audits and quality improvement initiatives related to clinical documentation.
• Maintain knowledge of healthcare regulations, payer requirements, and industry standards relevant to clinical documentation and coding.
• Use CDI software tools and electronic health records (EHR) systems effectively to facilitate documentation improvement.

Education:

• Bachelor's degree Science or Life science or related healthcare field preferred.
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification required.

Experience:

• Minimum 4 years of experience in medical coding with demonstrated expertise in multi-specialty E/M, inpatient, outpatient, and ED professional fee coding.
• Prior experience in coding analysis, auditing, and training is highly desirable.

Skills:

• Strong knowledge of CPT, ICD-10-CM, HCPCS coding guidelines and payer policies, particularly for professional fee services.
• Knowledge of medical terminology, anatomy, physiology, and clinical processes.