Clinical Documentation Integrity (CDI) Specialist - 252168

Clinical Documentation Integrity (CDI) Specialist

Location: Los Angeles, CA (100% Onsite)

Compensation: $50.00 – $64.00 per hour (Commensurate with experience)

Schedule: Monday – Friday | 8:00 AM – 5:00 PM

Position Overview

We are seeking a highly skilled and detail-oriented Clinical Documentation Integrity (CDI) Specialist to join a premier healthcare team in Los Angeles. This role is pivotal in ensuring that clinical documentation accurately reflects the severity of illness (SOI) and risk of mortality (ROM) for our patient population. The ideal candidate will bridge the gap between clinical care and data integrity, collaborating directly with providers to ensure the highest standards of medical record accuracy and regulatory compliance.

Key Responsibilities

Clinical Record Governance

• Conduct concurrent and retrospective reviews of inpatient and/or outpatient medical records to identify documentation gaps, inconsistencies, or missing diagnoses.
• Validate that clinical indicators support documented diagnoses, including Principal and Secondary diagnoses (CC/MCCs, HCCs), procedures, and POA status.
• Ensure all documentation accurately captures the complexity of patient care to support appropriate SOI and ROM levels.

Provider Engagement & Query Management

• Initiate compliant, clinically sound queries to medical staff to clarify complex diagnoses and procedures.
• Adhere strictly to ACDIS and AHIMA guidelines to ensure all queries remain non-leading and ethically sound.
• Track query response rates and provide real-time feedback to physicians to improve longitudinal documentation habits.

Strategic Education & Collaboration

• Deliver targeted documentation training and best-practice education to providers and clinical staff.
• Partner with Coding, Quality, Case Management, and Utilization Review teams to reconcile gaps and ensure audit readiness.
• Support the onboarding process for new clinicians, setting clear expectations for documentation quality.

Compliance & Data Oversight

• Monitor departmental KPIs, including query rates, response times, and documentation improvement trends.
• Support quality metrics related to mortality, complications, readmissions, and patient safety indicators.
• Ensure continuous adherence to CMS and third-party payer regulations.

Job Qualifications

Required Qualifications:

• Clinical Licensure: Active RN, MD, DO, PA, NP, or ECFMG certification.
• Experience: 1–2 years of recent clinical experience, CDI-specific experience, or a relevant Coding background.
• Technical Knowledge: Deep proficiency in disease processes, ICD-10-CM/PCS coding concepts, and DRG/HCC methodologies.
• Systems: Proficiency with Electronic Health Record (EHR) platforms.
• Communication: Exceptional professional communication and conflict resolution skills, with the ability to influence executive leadership and medical staff.

Required Certifications (Post-Hire):

• Current Los Angeles County Fire Card (or obtained within 30 days of hire).
• Assault Response Competency (ARC) certification (or obtained within 30 days of hire).

Preferred Qualifications:

• Industry Credentials: CCDS, CCDS-O, CDIP, CCS, CPC, RHIA, or RHIT.
• Clinical Background: Prior experience in acute care settings, risk adjustment, or outpatient CDI initiatives.
• Guideline Expertise: Familiarity with ACDIS and AHIMA CDI professional standards.

Core Competencies

• Analytical Thinking: Strong clinical critical thinking skills to identify nuanced documentation opportunities.
• Operational Excellence: Ability to work independently in a high-volume, accuracy-driven environment.
• Organization: Superior time-management skills with the ability to prioritize urgent reviews and interdisciplinary collaboration.