CDI Specialist: Elevate Documentation & Compliance

Lyndon Baines Johnson Tropical Medical Center; Fagaʻalu, Tafuna (AS, AS); On-site; USD 31,000 - 54,000; Full time

Job summary

LBJ Tropical Medical Center is seeking a Clinical Documentation Integrity (CDI) Specialist to improve medical record documentation, ensuring accurate severity of illness, risk of mortality, and CMS-compliant reimbursement.

You will collaborate with physicians, coding staff, quality teams, and case management to identify documentation gaps, perform reviews, and educate providers on documentation best practices across inpatient and designated outpatient settings.

Qualifications

• RN/MD/PA/NP licensure or equivalent clinical credential.
• Experience with clinical documentation integrity concepts.
• Familiarity with ICD-10-CM/PCS and CMS guidelines.

Responsibilities

• Review inpatient and designated outpatient records to identify gaps and opportunities for improvement.
• Ensure documentation supports diagnoses, procedures, POA indicators, SOI, and ROM.
• Collaborate with coding teams to ensure accurate code assignment based on documentation.
• Provide compliant, non-leading provider queries and follow-up for clarification.
• Educate providers on documentation best practices and participate in interdisciplinary rounds.

Skills

Clinical documentation

CMS guidelines

Coding collaboration

Education & training

Education

Registered Nurse (RN)

Physician (MD/DO)

Physician Assistant (PA)

Nurse Practitioner (NP)

Physician with U.S. clinical documentation experience

Certified Professional Coder (CPC) or equivalent coding certification

Job description

LBJ Tropical Medical Center is seeking a Clinical Documentation Integrity (CDI) Specialist to improve medical record documentation, ensuring accurate severity of illness, risk of mortality, and CMS-compliant reimbursement.

You will collaborate with physicians, coding staff, quality teams, and case management to identify documentation gaps, perform reviews, and educate providers on documentation best practices across inpatient and designated outpatient settings.