CDI QA Reviewer & Educator - Documentation Excellence

Washington Hospital Healthcare System; Fremont (CA); On-site; USD 140,000 - 210,000; Full time

Job summary

Washington Hospital Healthcare System invites applications for a CDI QA Reviewer & Educator to strengthen clinical documentation quality across the organization through comprehensive audits, targeted education, and expert guidance.

This role conducts detailed reviews of medical record documentation and CDI workups to ensure compliance with ICD-10-CM/PCS, DRG methodology, and regulatory standards while supporting accurate and defensible documentation practices.

Qualifications

• Bachelor’s degree in Nursing or related healthcare field required.
• Preferred: Master’s degree in Nursing, Education, or Healthcare Management or equivalent experience.
• Credentials: CCDS, CDIP, or CCS or equivalent credential required.
• RN license and/or AHIMA ICD-10 trainer credential preferred.

Responsibilities

• Perform routine and ad hoc audits of CDI reviews, provider documentation, and query practices to assess accuracy, completeness, and compliance with internal standards and national guidelines.
• Validate ICD-10-CM/PCS, DRG assignment, and coding alignment with clinical evidence and UHDDS/CMS requirements.
• Identify documentation trends, variances, and opportunities for improvement across CDI teams and clinical departments.
• Maintain audit tools, track performance metrics, and present findings to CDI and HIM leadership.
• Support retrospective audits requested by hospital leadership or system-wide initiatives.
• Develop and deliver CDI education programs, onboarding, continuing education, and skills refreshers for CDI specialists.
• Provide targeted provider education on documentation best practices, query response expectations, and regulatory changes.
• Create educational materials, tutorials, tip sheets, and presentations; may prepare CEU-eligible content.
• Offer one-on-one coaching based on audit findings or performance trends.
• Participate in CDI program development, education committees, and system-wide documentation improvement initiatives.
• Partner with coding, HIM, compliance, and CDI leadership to ensure alignment of documentation, coding, and query standards.
• Act as a liaison between CDI, physicians, clinical quality, and patient financial services to support documentation accuracy and revenue integrity.
• Support implementation of new documentation guidelines, EHR tools, and CDI workflows.
• Ensure compliance with federal and state regulatory requirements and organizational policies.

Skills

CDI reviews

DRG methodology

Documentation guidelines

CDIS education

Communication skills

Education

Bachelor’s degree in Nursing or related healthcare field

Master’s degree in Nursing, Education, or Healthcare Management or equivalent experience

CCDS, CDIP, or CCS or equivalent credential

RN license and/or AHIMA-approved ICD-10 trainer credential

Job description

Washington Hospital Healthcare System invites applications for a CDI QA Reviewer & Educator to strengthen clinical documentation quality across the organization through comprehensive audits, targeted education, and expert guidance.

This role conducts detailed reviews of medical record documentation and CDI workups to ensure compliance with ICD-10-CM/PCS, DRG methodology, and regulatory standards while supporting accurate and defensible documentation practices.