Clinical Documentation Integrity (CDI) Specialist

Education & Credentials:

• Bachelors degree in Nursing (BSN) or Bachelors in Physiotherapy or related field, Health Information Management, or related field (required)
• CDI Certification: CCDS (Certified Clinical Documentation Specialist) or CDIP (AHIMA)
• Clinical background (RN, MD, or HIM professional) with at least 37 years of CDI experience
  

Experience:

• Proven experience in Clinical Documentation Integrity programs within acute care hospitals or physician practices
• Deep understanding of MS-DRG and APR-DRG assignment logic and the impact of documentation on reimbursement and quality metrics
• Experience in query creation, CC/MCC identification, severity of illness (SOI) and risk of mortality (ROM) scoring
• Exposure to case mix index (CMI) analysis and denial prevention related to documentation
• Familiarity with ICD-10-CM/PCS, CPT, and HCPCS coding guidelines
• Prior experience collaborating with product teams or developing logic/rules for CDI or RCM systems is a plus

Key Responsibilities

1. CDI Logic Development:

• Define and document CDI logic rules and triggers based on national CDI guidelines and payer documentation requirements
• Develop condition-specific CDI rulesets (e.g., sepsis, respiratory failure, encephalopathy, malnutrition)
• Maintain mapping between diagnoses, clinical indicators, and supporting lab/imaging evidence
• Build logic libraries for query opportunities, denial risk flags, and missing documentation alerts
  

2. Standards and Compliance:

• Ensure all CDI logic aligns with AHIMA & ACDIS standards, CMS Official Coding Guidelines, and OIG compliance
• Monitor updates from CMS and other regulatory bodies and update CDI rules accordingly

3. Collaboration & Testing:

• Collaborate with product and data teams to translate CDI rules into machine-readable logic
• Participate in UAT (User Acceptance Testing) to validate CDI outputs and ensure logic accuracy
• Partner with SMEs in coding, quality, and utilization review to refine the CDI algorithms
  

4. Knowledge Management:

• Create and maintain a CDI knowledge base of condition-specific documentation guidance
• Train internal stakeholders (developers, QA, data scientists) on CDI logic interpretation

Skills & Competencies

• Expert knowledge of ICD-10-CM/PCS coding conventions
• In-depth understanding of clinical indicators, pathophysiology, and clinical validation concepts
• Strong grasp of CC/MCC capture, DRG shifts, SOI/ROM impact, and query compliance
• Excellent written communication skills for authoring logic documentation and clinical justifications
• Analytical mindset with ability to think in rules, hierarchies, and logic trees
• Comfortable working in cross-functional teams including clinicians, product managers, and engineers