Outpatient CDI Specialist: Elevate Documentation & Coding

Illinois Bone & Joint Institute, LLC; Park Ridge (IL); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life and AD&D insurance

Disability insurance

401k with company match

Profit sharing

Wellness program

Health Savings Account (HSA)

Flexible Spending Accounts (FSA)

Paid holidays

Paid time off

Job summary

Illinois Bone & Joint Institute, LLC (IBJI) seeks an Outpatient CDI Specialist to enhance documentation accuracy and coding quality across Illinois clinics. You will conduct audits, provide provider education, and collaborate with Coding, Revenue Cycle, and Epic teams to support compliant charge capture.

The role emphasizes AI-assisted coding review, workflow improvements, and maintaining HIPAA confidentiality while advancing documentation integrity and revenue protection.

Qualifications

• Associate degree in Health Information Management, Health Information Technology, Nursing, or related healthcare field preferred; equivalent relevant experience may be considered.
• Current professional coding credential such as CPC, CCS, CCS-P, or equivalent strongly preferred; auditing/CDI credentials preferred

Responsibilities

• Performs prospective and retrospective audits of outpatient clinical documentation, coding, and charge capture to validate accuracy, completeness, medical necessity, and compliance with applicable coding and payer requirements
• Reviews provider documentation and coded services for appropriate diagnosis, CPT, HCPCS, modifier, and E/M code selection and identifies opportunities for clarification or correction
• Provides clear, timely, and actionable feedback to physicians, advanced practice providers, coders, and operational teams regarding documentation and coding findings
• Develops and delivers provider education based on audit findings, coding trends, payer changes, regulatory guidance, and identified documentation opportunities
• Manages and monitors documentation and coding send-backs, including appropriate follow-up with providers and coders to support timely resolution and claim submission
• Partners with coding leadership and coding staff to review recurring coding questions, reconcile documentation and coding discrepancies, and promote consistent coding practices
• Coordinates with the Epic team on Revenue Cycle and CDI-related workflow, edit, workqueue, reporting, charge capture, and documentation enhancement opportunities; participates in testing and user acceptance testing (UAT) as needed
• Audits AI-assisted and automated coding output for accuracy, compliance, and consistency; identifies error patterns, documents findings, and collaborates with coding and technology teams on corrective actions and optimization
• Supports Revenue Integrity activities, including review of charge capture, missed or incorrect charges, coding edits, modifier use, billing rules, and workflow opportunities that may affect compliant reimbursement
• Identifies trends that may contribute to denials, claim edits, delayed billing, coding rework, or revenue leakage and partners with Revenue Cycle teams to develop sustainable solutions
• Assists with the development and maintenance of coding, CDI, and Revenue Integrity policies, procedures, tip sheets, education materials, and standardized workflows
• Tracks and reports audit results, provider education activity, send-back volumes, error trends, and improvement opportunities; escalates significant or recurring findings to leadership
• Participates in Revenue Cycle change control, Epic optimization, and process improvement initiatives that impact coding, documentation, charge capture, and claims
• Maintains current knowledge of ICD-10-CM, CPT, HCPCS, NCCI edits, payer policies, Medicare requirements, and other applicable coding and billing guidance
• Maintains confidentiality of patient information in accordance with HIPAA and organizational policies
• Supports departmental goals, quality initiatives, and other Revenue Cycle responsibilities as assigned
• Maintain a clean and safe work environment
• Other duties as assigned

Skills

ICD-10-CM

CPT

HCPCS

E/M coding

NCCI edits

Auditing

Epic experience

Charge capture

Data analysis

Communication

Education

Associate degree in Health Information Management

CPC/CCS/CCS-P or equivalent preferred

CPMA/CDIP/CDDS-O or CDI auditing credential preferred

Tools

Epic

MS Office

Coding software

Job description

Illinois Bone & Joint Institute, LLC (IBJI) seeks an Outpatient CDI Specialist to enhance documentation accuracy and coding quality across Illinois clinics. You will conduct audits, provide provider education, and collaborate with Coding, Revenue Cycle, and Epic teams to support compliant charge capture.

The role emphasizes AI-assisted coding review, workflow improvements, and maintaining HIPAA confidentiality while advancing documentation integrity and revenue protection.