CDI Specialist - Orthopedics

Responsibilities

• Clinical documentation review:
  Conduct 100% systematic reviews of outpatient clinic medical records to ensure documentation is specific, complete, and compliant with coding guidelines and regulatory standards.
• Provider collaboration:
  Interact with physicians and other clinicians to clarify conflicting, imprecise, or incomplete documentation through written queries or verbal communication.
• Education and training:
  Educate providers on proper documentation techniques and the impact of documentation on Hierarchical Condition Categories (HCCs), coding accuracy, and quality metrics.
• Coding and compliance:
  Apply knowledge of coding guidelines (e.g., ICD-10, CPT) and reimbursement methodologies (e.g., HCCs) to assess if documentation supports the services billed.
• Data analysis:
  Track and analyze key CDI data, such as query rates and documentation trends, to identify opportunities for process improvement and targeted education.
• Audit support:
  Assist with internal and external audits by providing clinical expertise and supporting documentation for claim reviews.
• Quality improvement:
  Work with interdepartmental teams, such as quality and case management, to improve documentation related to core measures and other patient safety indicators.

• Education:
  
  Associate or bachelor's degree in nursing (RN) or Health Information Management (RHIA/RHIT) is required.
• Certification:
  Relevant professional certifications such as Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), or Certified Coding Specialist (CCS) are highly preferred.
• Experience:
  
  A minimum of 2–3 years of recent clinical experience in an outpatient or acute care setting is typically required. Experience in coding, utilization review, or case management is also beneficial.

• Strong clinical knowledge and understanding of disease processes.
• Excellent written and verbal communication and interpersonal skills.
• Exceptional critical thinking and analytical abilities.
• Proficiency with electronic health records (EHR) and other CDI software.
• Ability to work independently and manage time effectively.

• Entry level

• Full-time

• Health Care Provider
• Hospitals and Health Care