Ambulatory CDI Specialist: Chart Integrity & Education

Carle-Health; Champaign (IL); On-site; USD 36,000 - 60,000; Full time

Job summary

Carle Health seeks an Ambulatory Clinical Documentation Improvement (CDI) specialist to review diagnostic and E/M codes based on chart documentation. The role supports clinical care, teaches CPT E/M, CPT procedures, ICD10CM coding, and ensures compliance with regulatory requirements across the coding team and providers.

Responsibilities include education, audits, and remediation, with collaboration among HIM leadership.

Qualifications

• Certifications listed include CCS, RHIT, RHIA, CPCH, CPC, COC, CIC, CCS-P.
• AHIMA/AAPC credentials are required or strongly preferred.
• Detailed coding education and regulatory knowledge expected.

Responsibilities

• Review quality and completeness of diagnostic and E/M codes with emphasis on documentation.
• Apply medical terminology, anatomy, physiology, disease processes, treatments, diagnostics, meds and procedures to ensure proper code assignment.
• Adhere to coding practices, guidelines, conventions and hospital/policy requirements.
• Assist facility staff with documentation requirements to reflect care provided.
• Provide regular coding reviews and feedback on ICD10CM, CPT E/M or CPT Surgical coding.
• Provide education and education materials related to coding for team and providers.
• Follow query and notification process and escalate as needed.
• Provide statistics around changed/deleted codes to Manager/Director regularly.
• Escalate results to Compliance as required by audit policy/practice.

Education

CCS - AHIMA

RHIT - AHIMA

RHIA - AHIMA

CPCH - AAPC

CPC - AAPC

COC - AAPC

CIC - AAPC

CCS-P - AHIMA

Tools

CPT E/M coding

CPT Procedural Coding

ICD10CM coding

Job description

Carle Health seeks an Ambulatory Clinical Documentation Improvement (CDI) specialist to review diagnostic and E/M codes based on chart documentation. The role supports clinical care, teaches CPT E/M, CPT procedures, ICD10CM coding, and ensures compliance with regulatory requirements across the coding team and providers.

Responsibilities include education, audits, and remediation, with collaboration among HIM leadership.