Exceptional Healthcare Inc.
CDI Specialist
Dallas, TX · Full-time
Posted · Listed from JazzHR
About the job
Job Responsibilities/Duties:
- CLINICAL DOCUMENTATION REVIEW
- Conduct concurrent and/or retrospective medical record reviews to assess documentation accuracy, completeness, and specificity.
- Identify documentation opportunities to clarify diagnoses, procedures, complications, comorbidities, and clinical indicators.
- Ensure documentation supports medical necessity and accurate MS-DRG/APR-DRG assignment.
- Serve as a technical expert in health record content and documentation requirements within the EHR.
- PROVIDER COLLABORATION & QUERY PROCESS
- Initiate compliant, non-leading queries to physicians and providers to obtain clarification of diagnoses and procedures.
- Collaborate with coders to ensure discharge diagnoses accurately capture clinical status and care delivered.
- Educate providers on documentation best practices, coding guidelines, and regulatory requirements.
- Foster positive working relationships with medical staff to support documentation improvement initiatives.
- REGULATORY COMPLIANCE & QUALITY
- Ensure documentation complies with CMS, AHIMA, ACDIS, and other regulatory standards.
- Monitor and support quality metrics, including case mix index (CMI), hospital-acquired conditions (HACs), PSI indicators, and value-based purchasing measures.
- Maintain audit-ready documentation practices.
- Develop and update documentation policies in alignment with CIHQ accreditation standards.
- DATA ANALYSIS & REPORTING
- Track and report key CDI metrics such as query response rate, agreement rate, CMI trends, and financial impact.
- Participate in internal audits and performance improvement initiatives.
- Identify trends and recommend workflow or educational improvements.
- Provide ongoing education to providers and staff regarding documentation guidelines and regulatory updates.
- Support denial management by providing clinical justifications for appealed claims.
- Perform other duties as assigned.
- Associate or bachelor’s degree in nursing, Health Information Management, or related healthcare field required.
- RN, RHIA, RHIT, CCS, CCDS, CDIP, or other relevant certification preferred (or required within a specified timeframe).
- Minimum 3 years clinical experience in acute care; ER, ICU, med-surg, or case management preferred.
- Minimum 2 years CDI experience with concurrent record review and physician querying.
- Current unencumbered RN license in the state of practice (if nursing background).
- CCDS (ACDIS) or CDIP (AHIMA) certification preferred.
- Additional coding credentials (CCS, CPC, CIC) a plus.
PHYSICAL DEMANDS
- Prolonged sitting at a desk and working on a computer for medical record review.
- Adequate vision, hearing, and repetitive hand/wrist motions required.
- Ability to move about the facility for physician rounding and training sessions.
WORK CONDITIONS
- Well lighted, heated and/or air-conditioned indoor clinical/office setting with adequate ventilation.
- On-site
- Travel to ECH hospital locations may be required.
Exceptional Healthcare Inc. wrote this description; Job Elf found it on JazzHR. Check details with the employer before you share anything sensitive. Never pay to apply for a job.
More jobs at Exceptional Healthcare Inc.
Full-time
Posted 5 days ago Apply on company site
Full-time
Posted 5 days ago Apply on company site
Full-time
Posted 5 days ago Apply on company site
Part-time
Posted 6 days ago Apply on company site
More jobs in Dallas, TX
Full-time
Posted today Apply on company site
$110,000 – $165,000 per year · Full-time
Posted today Apply on company site
Full-time
Posted today Apply on company site
Full-time
Posted today Apply on company site