Perioperative Clinical Documentation Integrity (CDI) Specialist

The Essentials:

• Schedule: Full-Time (40 hrs/week) | 1^st Shift | Exempt
• Location: Fairlawn, OH
• Specialties: Health Information Management

What You’ll Do:

• Ensures accurate, timely capture of surgical procedures in the electronic medical record (EMR).
• Reviews perioperative documentation to ensure surgical procedures performed align with payer authorization requirements and the services ultimately reported for billing.
• Collaborates with surgeons, clinical teams, coders, and authorization staff to support clear documentation, appropriate payer notification, and supports the Health Information Management (HIM) department by promoting documentation practices that support accurate coding, revenue integrity, and regulatory compliance within the EMR.

What We’re Looking For:

• Education: Associate’s or Bachelor’s degree in Health Information Management or a related field required.
• Experience: 4 – 7 years’ experience in hospital coding, clinical documentation review, or surgical services. Familiarity with CPT procedural coding. Experience reviewing operative documentation, knowledge of payer authorization processes. Experience working within Cerner or similar EMR system. Clinical experience with surgical or procedural documentation, preferred.
• Skills: Strong understanding of surgical documentation and procedural workflows. Ability to analyze clinical documentation for coding and authorization implications. Effective communication skills when collaborating with physicians and clinical teams. Ability to work collaboratively across HIM, coding, and revenue cycle departments. Strong organizational and analytical skills. Ability to work in a fast-paced surgical environment.
• License/Certifications: RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator), CCDS, CDIP, CCS or CPC required. Active clinical licensure of RN or LPN preferred.