Senior Clinical Documentation Specialist (CDI)

About the role

The Senior Clinical Documentation Specialist leads comprehensive reviews of inpatient medical records, identifies documentation gaps, and ensures accurate coding and DRG assignment. This role collaborates closely with physicians, coders, and clinical teams to improve documentation quality and compliance.

Key responsibilities

• Conduct thorough reviews of inpatient medical records to identify gaps and clarification opportunities.
• Develop and issue compliant physician queries to resolve documentation issues.
• Evaluate clinical indicators, diagnoses, procedures, and severity of illness (SOI)/risk of mortality (ROM) for coding accuracy.
• Support accurate ICD-10-CM/PCS and DRG assignment.
• Monitor CDI quality, productivity, and query performance metrics.
• Provide guidance, mentoring, and participate in audits and quality improvement initiatives.

Required profile

• Active PHRN license (USRN preferred).
• Minimum 3‑5 years clinical experience, preferably in acute/inpatient care.
• At least 5 years inpatient CDI experience with US healthcare exposure.
• Strong knowledge of ICD‑10‑CM/PCS, DRGs, CC/MCCs, SOI and ROM.

Required skills

• ICD‑10‑CM/PCS coding expertise.
• DRG assignment and severity of illness analysis.
• Experience with Epic or other major EHR platforms.
• CDI certification (e.g., CDIP, CCDS, CIC) highly preferred.