Clinical Document Improvement Specialist
Description:
Clinical Documentation Improvement (CDI) Specialist – CDI-coder
The Clinical Documentation Improvement (CDI) Specialist – CDI-coder is responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure complete, accurate, and compliant clinical documentation. This role focuses on supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity. This role works closely with providers, coders, and quality teams to clarify documentation and support accurate data capture for clinical, financial, and regulatory reporting.
Primary Department, Division, or Unit: Clinical Documentation Improvement, UHS Revenue Cycle Operations
Primary Work Shift: Day
Regular Scheduled Weekly Hours: 40
Compensation Range: $30.58 - $45.86 per hour, depending on experience
Education/Experience
Minimum Required:
RHIT certification with an Associate degree in HIT.
Minimum 2–5 years of inpatient hospital coding experience
Preferred:
RHIA certification with a Bachelor's Degree in HIT.
License/Certification
Minimum Required:
RHIT certification
Preferred:
RHIA certification
CCS (Certified Coding Specialist) – AHIMA-preferred
CIC (Certified Inpatient Coder)-AAPC-preferred
CCDS (Certified Clinical Documentation Specialist)–ACDIS- preferred