Clinical Documentation Improvement (CDI) Specialist

SoTalent

Escondido (CA)

On-site

USD 74,000 - 124,000

Full time

14 days+

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Job summary

SoTalent is seeking a Clinical Documentation Improvement (CDI) Specialist to enhance the accuracy of clinical documentation in a hospital setting. The role involves reviewing medical records, collaborating with healthcare providers, and ensuring compliance with coding standards. Ideal candidates will have a Bachelor's degree, relevant credentials, and experience in clinical documentation. This full-time position offers a competitive salary and the opportunity to contribute to healthcare quality.

Qualifications

Bachelor's degree required.
Must hold RN or MD credentials.
At least 2 years of experience in clinical documentation review.

Responsibilities

Conduct in-depth reviews of inpatient medical records.
Perform concurrent documentation assessments for admitted patients.
Initiate clarification queries for documentation inconsistencies.

Skills

Analytical thinking

Communication skills

Attention to detail

Education

Bachelor's degree

Tools

Electronic health records

Clinical coding software

Job description

Clinical Documentation Improvement (CDI) Specialist

1 day ago Be among the first 25 applicants

This range is provided by SoTalent. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$74,000.00/yr - $124,000.00/yr

Overview:

In this role, you will conduct in-depth reviews of inpatient medical records to assess whether clinical documentation accurately conveys the patient's condition and aligns with current healthcare coding and regulatory standards. You'll collaborate with a variety of internal stakeholders—such as coding professionals, case managers, quality teams, and healthcare providers—to support accurate representation of patient acuity and clinical complexity.

Key Responsibilities:

Perform concurrent documentation assessments for patients currently admitted, ensuring thorough and timely physician notes are present by the time of discharge.
Evaluate new daily admissions on designated units, assign preliminary diagnosis-related groups (DRGs), and log information in the appropriate clinical review platform or worksheet.
Modify DRG assessments as additional provider documentation or query responses clarify or change patient acuity.
Alert team leadership if assigned workload becomes unmanageable or requires redistribution to meet departmental goals.
When inconsistencies or gaps in documentation are discovered, initiate structured and compliant clarification queries in accordance with recognized best practices from professional associations.
Work to secure prompt and accurate responses to all clinical documentation inquiries sent to physicians or other care providers.

Qualifications:

Bachelor's degree required.
Must hold one of the following professional credentials: Registered Nurse (RN), Doctor of Medicine (MD), or international equivalent (e.g., MBBS).
At least 2 years of recent experience in inpatient medical coding or clinical documentation review within a hospital setting.
Proficient in DRG logic, ICD coding conventions, and use of encoder tools.
Must stay informed on the latest updates to coding regulations and documentation standards.

Preferred Experience and Skills:

Industry certifications such as CCDS (Certified Clinical Documentation Specialist) or CDIP (Clinical Documentation Improvement Practitioner) are highly desirable.
Strong grasp of clinical pathophysiology and the progression of common inpatient diagnoses.
Demonstrated ability to apply analytical thinking and exercise sound clinical judgment.
Excellent communication skills, especially when clarifying documentation with medical staff in complex or sensitive cases.
Comfortable using electronic health records, clinical coding software, and productivity tracking systems.

This position is a great fit for healthcare professionals with a keen eye for detail, a passion for improving clinical documentation quality, and a desire to contribute to organizational excellence in health information accuracy and compliance.

Seniority level