Clinical Documentation Integrity (CDI) Specialist

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

EMPLOYMENT OPPORTUNITY

September 11, 2026

The Department of Human Resources is accepting applications for the following position.

Job Title: Clinical Documentation Integrity (CDI) Specialist

Department: Business Affairs & Audits

Reports to: Chief of Business Affairs & Audits

Salary: $30,882,46 – $54,152.58

Position Summary

The Clinical Documentation Integrity (CDI) Specialist is responsible for improving the accuracy, completeness, and clinical specificity of medical record documentation to ensure that the patient’s severity of illness, risk of mortality, quality metrics, and reimbursement are accurately reflected in compliance with CMS, ICD-10-CM/PCS, procedural coding standards, and applicable regulatory requirements.

The CDI Specialist works collaboratively with providers, coding professionals, quality teams, and case management staff to support compliant documentation practices across all inpatient and designated outpatient settings.

Essential Duties and Responsibilities

Clinical Documentation Review

• Review inpatient and designated outpatient medical records concurrently and/or retrospectively to identify documentation gaps, inconsistencies, and opportunities for improvement.
• Ensure documentation accurately supports:
  • Principal diagnoses
  • Secondary diagnoses
  • Procedures and procedural codes
  • Present on Admission (POA) indicators
  • Severity of Illness (SOI)
  • Risk of Mortality (ROM)
• Apply ICD-10-CM/PCS Official Guidelines for Coding and Reporting when evaluating documentation sufficiency and clinical specificity.
• Collaborate with coding teams to ensure accurate code assignment based on documentation.

Provider Query Management

• Issue compliant, non-leading verbal and written provider queries in accordance with:
  • CMS documentation guidelines
  • Industry best practices
  • Organizational policies
• Follow up with providers to obtain timely clinical clarification.
• Maintain a collaborative and educational approach when communicating documentation opportunities.
• Monitor and track query response rates, turnaround times, and outcomes.

Collaboration and Education

• Serve as a clinical documentation resource for:
  • Physicians
  • Advanced Practice Providers (APPs)
  • Coding professionals
  • Case Management
  • Quality Management
  • Utilization Review staff
• Provide ongoing education and guidance regarding:
  • Documentation best practices
  • Diagnosis specificity
  • Clinical indicators
  • Quality measures
  • Audit preparedness
• Participate in interdisciplinary rounds and clinical improvement initiatives as applicable.

Coding, Quality, and Revenue Integrity Support

• Partner closely with coding staff to resolve documentation issues impacting code assignment and reimbursement.
• Support hospital compliance with:
  • Medicare Conditions of Participation
  • CMS regulations and documentation standards
  • Audit readiness initiatives (MAC, RAC, OIG, and other regulatory reviews)
• Assist in identifying documentation trends affecting:
  • Reimbursement
  • Quality reporting
  • Denials and appeals
  • Revenue integrity

Data Tracking and Reporting

• Maintain and monitor CDI performance metrics, including:
  • Number of reviews completed
  • Query volume and response rates
  • Documentation improvement outcomes
  • Audit findings and compliance measures
• Analyze documentation trends and identify opportunities for improvement.
• Prepare reports and communicate findings to departmental leadership.

Compliance and Ethics

• Ensure all CDI activities are conducted in a compliant, ethical, and non-leading manner.
• Adhere to:
  • Hospital policies and procedures
  • HIPAA regulations
  • Applicable federal, territorial, and accreditation requirements
• Escalate documentation, compliance, or ethical concerns through appropriate channels.

Qualifications

Required Qualifications

Licensure/Certification

Must possess one of the following:

• 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

Knowledge and Experience

Strong understanding of:

• Clinical disease processes
• Medical terminology
• ICD-10-CM/PCS coding concepts
• Clinical documentation integrity principles
• Interpretation of clinical indicators and correlation to documentation requirements

Working knowledge of:

• CMS reimbursement methodologies
• Medicare regulations
• Audit readiness processes
• Denial prevention and appeals management

Skills and Competencies

• Strong clinical judgment and critical thinking skills
• Excellent written and verbal communication skills
• Ability to educate, influence, and collaborate effectively with providers
• Strong analytical and problem-solving abilities
• Detail-oriented with exceptional organizational skills
• Ability to manage multiple priorities and deadlines
• Proficiency with Electronic Health Record (EHR) systems and clinical documentation workflows
• Ability to maintain confidentiality and professionalism in all interactions