CDI Specialist: Elevate Documentation Quality

Cape Cod Healthcare Inc; Hyannis (MA); On-site; USD 70,000 - 100,000; Full time

Job summary

Cape Cod Healthcare is seeking a Clinical Documentation Improvement Specialist to review medical records and improve physician documentation to accurately reflect illness severity. The role involves risk adjustment reviews, coding verification, and education of clinical staff, with emphasis on collaboration with physicians and care teams.

Located in Hyannis, MA, this full-time position supports CAPABILITY OF CARES values while ensuring compliance with ICD-10-CM guidelines.

Qualifications

• Associate’s Degree in a relevant field preferred or combination of equivalent education and experience.
• Certified Professional Coder (CPC) certification required.
• Knowledge of clinical documentation guidelines and CDI program implementation experience preferred.
• Knowledge of ICD-10-CM, CPT codes, and disease processes.
• AHIMA/ACDIS CCDS/CDIP preferred but not required.

Responsibilities

• Review medical records to verify diagnosis codes are supported by documentation and ICD-10-CM guidelines.
• Assess whether diagnosis codes capture severity of illness and communicate with providers.
• Educate practice office physicians and staff on documentation needs and coding issues.
• Obtain clinical documentation through interaction with physicians and care teams.
• Generate accurate status reports for physicians and leadership.
• Perform other duties as assigned.

Skills

Organizational skills

Analytical skills

Writing skills

Interpersonal skills

Critical thinking

Problem solving

Education

Associate’s Degree in a relevant field

Certified Professional Coder (CPC) certification

CDIS or CDIP in active status with AHIMA or ACDIS (preferred)

Job description

Cape Cod Healthcare is seeking a Clinical Documentation Improvement Specialist to review medical records and improve physician documentation to accurately reflect illness severity. The role involves risk adjustment reviews, coding verification, and education of clinical staff, with emphasis on collaboration with physicians and care teams.

Located in Hyannis, MA, this full-time position supports CAPABILITY OF CARES values while ensuring compliance with ICD-10-CM guidelines.