What are the responsibilities and job description for the Clinical Documentation Improvement (CDI) Specialist position at SoTalent?
Job Title: Clinical Documentation Improvement (CDI) Specialist
Location: Escondido, California, United States
Type: Full Time
Our client, is seeking a detail-oriented Clinical Documentation Improvement (CDI) Specialist to support accurate and compliant clinical documentation practices.
This role plays a key part in reviewing patient records, identifying documentation gaps, and ensuring clinical information accurately reflects patient acuity, severity of illness, and risk of mortality in accordance with current regulatory guidelines.
Key Responsibilities
- Perform detailed secondary reviews of clinical records to identify documentation improvement opportunities
- Conduct concurrent reviews of inpatient charts to ensure completeness and accuracy prior to discharge
- Evaluate new admissions and assign preliminary codes and working DRGs, updating them as clinical documentation evolves
- Maintain accurate data entry within CDI systems for all case reviews and follow-ups
- Collaborate with coding teams, auditors, case managers, providers, and quality teams to ensure compliance and documentation integrity
- Initiate and manage compliant physician queries when documentation requires clarification, and follow up to ensure timely responses
- Communicate workload concerns with leadership to support balanced review distribution
Required Qualifications
- Bachelor’s degree in a related field
- Clinical credential such as RN, MD, or equivalent (MBBS)
- 2–4 years of experience in inpatient coding or CDI within an acute care setting
- Knowledge of DRG assignment and coding tools/encoders
- Familiarity with official coding standards and regulatory guidelines
Preferred Qualifications
- CDI certifications such as CCDS or CDIP
- Strong clinical knowledge, including disease processes and medical terminology
- Proven analytical thinking and problem-solving abilities
- Comfort engaging with physicians to clarify documentation in complex scenarios
- Proficiency with EHR systems, CDI tools, and coding platforms
- Strong computer and typing skills