Health Information Specialist

The CDI Specialist conducts initial and secondary clinical chart reviews to identify documentation gaps and collaborate with Coders, Case Managers, Quality teams, and Providers to ensure documentation accurately reflects severity of illness, risk of mortality, and compliance with CMS and regulatory standards.Responsibilities:Perform concurrent review of inpatient records to ensure complete, accurate documentation at discharge for compliant codingComplete initial code and working DRG assignments; maintain CDI software entries for initial and follow-up reviewsUpdate working DRGs as documentation or query responses warrant changesInitiate compliant physician queries when documentation is ambiguous or incomplete; follow up promptly for responsesCollaborate with medical staff, clinical departments, and leadership to improve documentation performanceSupport CDI program operations including productivity, quality, education, auditing, and performance improvementIdentify opportunities to improve CDI metrics and develop standardized processes and best practicesWhat You Will Need:Bachelor's degreeActive RN, MD, or MD Equivalent (MBBS) license5+ years of acute care inpatient CDI experienceFamiliarity with encoders and DRG assignmentCurrent knowledge of official coding guidelines and Coding ClinicsWhat Would Be Nice to Have:CCDS or CDIP certificationStrong understanding of disease processes, medical terminology, anatomy, and physiologyCritical thinking and problem-solving skillsProficiency with EHR systems, CDI software, and encoders