Clinical Documentation Integrity (CDI) Review

The Clinical Documentation Integrity (CDI) Reviewer is responsible for reviewing clinical documentation to ensure it accurately reflects the patient's clinical condition and supports complete, compliant, and specific documentation. Leveraging knowledge of ICD-10, CPT, and other applicable coding guidelines, this role helps optimize risk adjustment, reimbursement, quality reporting, regulatory compliance, and clinical data integrity while partnering with providers, clinical teams, and operational leadership to improve documentation quality.

Key Duties and Responsibilities

Clinical Documentation Integrity Review

Review high-acuity patient medical records to identify clinical indicators, documentation gaps, and suspect diagnoses that may impact quality outcomes, risk adjustment, and reimbursement.

Analyze medical records to determine appropriate clinical information and identify opportunities for accurate diagnosis capture and documentation improvement.

Implement and execute clinical data review strategies in alignment with established protocols, program requirements, and organizational standards.

Ensure consistency, accuracy, and adherence to documentation review methodologies within assigned protocols while contributing to the development and implementation of new review processes.

Utilize clinical expertise and coding knowledge to identify opportunities for enhanced documentation accuracy, completeness, and specificity.

Collaborate with risk adjustment, case management, quality, and provider teams to ensure clinical documentation accurately reflects patient conditions, treatment decisions, and diagnoses.

Leverage physician query and communication processes to clarify documentation and improve the quality and completeness of the medical record.

Coding and Risk Adjustment Support

Identify and validate suspect diagnoses using clinical evidence and documentation standards.

Communicate clinical documentation requirements, coding guidelines, and regulatory standards to providers, coders, leadership, and other stakeholders.

Support coding validation efforts by ensuring documentation supports reported diagnoses and conditions.

Assist with provider and staff education regarding documentation improvement, coding compliance, risk adjustment methodologies, and diagnosis capture initiatives.

Data Management and Reporting

Maintain comprehensive tracking and management systems for assigned medical record reviews, findings, and outcomes.

Generate reports and communicate findings resulting from chart reviews to leadership and relevant stakeholders.

Monitor and maintain productivity, quality, and accuracy standards as defined by organizational performance metrics.

Compliance and Quality Assurance

Ensure all activities comply with HIPAA regulations, CMS guidelines, payer requirements, and organizational policies.

Participate in internal audits, quality assurance activities, and process improvement initiatives.

Maintain current knowledge of clinical documentation integrity practices, coding regulations, and industry best practices.

Perform other duties, special projects, and responsibilities as assigned.

Education and Experience

RN or NP/PA and a minimum of 3 years of progressive clinical experience

At least two (2) years of experience in chart review for clinical indications of medical conditions and diagnosis and management options with emphasis on the managed care industry

Coding certification is preferred but not required.

Strong understanding of ICD-10-CM coding guidelines, clinical documentation improvement principles, and physician query processes.

Experience reviewing provider documentation in outpatient, ambulatory, post-acute, primary care, or value-based care settings preferred.

Experience in working with various electronic health records (EHR) and medical records.

Essential Skills and Abilities

Strong clinical knowledge related to chronic illness diagnosis, treatment, and management

Familiarity and understanding of CMS HCC models, Risk Adjustment coding and data validation requirements (preferred)

Working knowledge of ICD-10-CM outpatient diagnosis coding guidelines (knowledge and demonstrated understanding of Risk Adjustment coding and data validation requirements is highly preferred)

Proficient in Microsoft Office Suite (Excel, Word, PowerPoint, Outlook) and other business applications, with strong spreadsheet and reporting skills.

Ability to review and analyze medical records across multiple EMR/EHR platforms.

Strong critical thinking, analytical, and problem-solving abilities.

Knowledge of ICD-10, clinical documentation standards, risk adjustment, and HIPAA compliance.

Excellent written and verbal communication skills with the ability to educate and collaborate with providers and interdisciplinary teams.

Ability to manage multiple priorities and meet strict deadlines in a fast-paced environment.

Self-motivated with the ability to work independently and remotely while maintaining productivity and accuracy.

Strong organizational skills, attention to detail, and commitment to confidentiality.

Ability to establish effective working relationships across departments, locations, and time zones.

Reliable, adaptable, and capable of handling sensitive information with professionalism and discretion.

Core Competencies

Instills trust

Customer focus

Manages ambiguity

Collaborates

Drives results