Inpatient CDI Specialist - Elevate Documentation

Shepherd Center; United States; On-site; USD 70,000 - 95,000; Full time

Job summary

Shepherd Center is seeking a Clinical Documentation Improvement (CDI) Specialist – Inpatient to ensure accurate and complete documentation within the medical record. The role partners with physicians, coding professionals, and interdisciplinary teams to support compliant coding, accurate reimbursement, and reliable quality reporting.

You will perform concurrent and retrospective reviews, identify opportunities to improve documentation related to diagnoses, SOI, ROM, and other risk factors, and

Qualifications

• Associate or Bachelor’s degree in Health Information Management, Nursing, or related healthcare field (or equivalent experience).
• RHIA, RHIT, or CCS credentials required.
• CDIP, CCDS, or CDEO credentials required.
• RN or LPN credentials required.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient medical records to evaluate documentation accuracy, completeness, and compliance.
• Identify opportunities to improve documentation related to diagnoses, procedures, severity of illness (SOI), and risk of mortality (ROM).
• Create and issue compliant provider queries to clarify documentation.
• Collaborate with physicians, nursing staff, and coding professionals to support accurate clinical documentation.
• Ensure alignment with ICD-10-CM coding guidelines, CMS regulations, and organizational policies.
• Utilize Epic CDI tools, work queues, and reporting dashboards to manage workload and track performance.
• Monitor documentation trends and elevate opportunities for improvement.
• Partner with Coding, Quality, Compliance, and Revenue Cycle teams to support documentation integrity.

Skills

Communication

Provider engagement

Analytical thinking

Documentation accuracy

Clinical terminology

Education

Associate or Bachelor’s degree in Health Information Management, Nursing, or related healthcare field (or equivalent experience).

Tools

Epic CDI

Job description

Shepherd Center is seeking a Clinical Documentation Improvement (CDI) Specialist – Inpatient to ensure accurate and complete documentation within the medical record. The role partners with physicians, coding professionals, and interdisciplinary teams to support compliant coding, accurate reimbursement, and reliable quality reporting.

You will perform concurrent and retrospective reviews, identify opportunities to improve documentation related to diagnoses, SOI, ROM, and other risk factors, and