Clinical Documentation Integrity (CDI) Specialist

Clinical Documentation Integrity (CDI) Specialist Location: Escondido, CA (Onsite for first 30 days; Hybrid thereafter) Schedule: Monday – Friday, 8:00 AM – 5:00 PM (Flexibility available; core hours required for meetings) Compensation: $35.00 – $50.00 per hour Position Overview The CDI Specialist is responsible for performing comprehensive initial and secondary clinical chart reviews to identify opportunities for documentation clarification. This role acts as a vital bridge between clinical care and data integrity, collaborating with Coders, Quality Auditors, Case Managers, and Providers to ensure patient records accurately reflect the severity of illness (SOI) and risk of mortality (ROM). The successful candidate will serve as an advocate for best-practice documentation, ensuring all records comply with CMS and other regulatory standards while building trusted relationships with medical staff and leadership. Key Responsibilities Clinical Review & Coding Accuracy Conduct daily concurrent reviews of inpatient records on assigned units to ensure complete documentation is present at the time of discharge. Perform initial code assignments for working DRGs and update them as clinical documentation or query responses evolve. Maintain a high level of productivity, averaging 22–25 reviews daily (initials and follow-ups). Utilize CDI software to enter data and submit comprehensive worksheets to the Program Assistant. Provider Engagement & Query Management Initiate compliant physician queries for ambiguous, confusing, or missing documentation, following AHIMA practice briefs. Maintain a 25% query rate and drive a 90% physician response rate . Facilitate bedside clinical dialogues and provide ongoing education to the medical staff regarding documentation nuances. Program Optimization & Quality Assist in developing processes and initiatives to improve clinical documentation performance across the health system. Maintain a 95% quality audit score on a monthly basis. Partner with the CDI Coordinator to manage volume fluctuations and ensure team-wide efficiency. Identify contractual and best-practice opportunities to improve CDI metrics and acuity capture. Required Qualifications Licensure: Valid Registered Nurse (RN) or Medical Doctor (MD) license. Experience: Minimum of 5 years of Inpatient CDI experience. Certification: Must hold CDIP (Certified Documentation Integrity Practitioner) or CCDS (Certified Clinical Documentation Specialist) credentials. Assessment: Must achieve a score of 80% or higher on the CDI Pre-Hire competency test. Preferred Skills & Attributes Clinical Expertise: Deep insight into pathophysiology, disease progression, anatomy, physiology, and microbiology. Analytical Reasoning: Proven problem-solving capabilities with the ability to navigate complex medical sciences. Communication: Skillful at managing sensitive consultations with physicians and collaborating with facility leadership. Technical Proficiency: Adept at high-speed data entry and proficient in EHR, CDI software, and encoding platforms. Professionalism: Ability to build strong, trustworthy relationships with client staff and multidisciplinary teams.