Clinical Documentation Improvement Specialist



Position Summary


(The below listed duties are not all inclusive. This position must also perform other duties as assigned.):

  • 30%: Perform concurrent and retrospective health record reviews to identify gaps within the clinical documentation for selected facilities within a facility region
  • 10%: Demonstrate proficiency in CDI regulatory requirements to include but not limited to: Documentation and Coding guidelines for professional fee-based coding: Evaluation and Management services, Procedures, and Diagnosis(es)
  • 10%: Provides orientation during onboarding of new providers and scribes on documentation requirements
  • 15%: Develops educational programs to providing ongoing training in response auditing findings or regulatory changes from CMS
  • 15%: Provides professional advice, feedback, and education on chart documentation to providers.
  • 10%: Responsible for reviewing medical record to determine documentation queries, track queries, and resolve queries
  • 10%: Maintains detail results of monitoring and auditing performed with documentation of necessary education, follow up and case specific findings. Report findings at end of month to Clinical Development


What specialized, technical, or practical knowledge, skills, experience, or abilities are needed to perform the job. (Include degrees, certificates, licenses, or other bona fide job qualifications.)


  • Licensure /Certification in coding (CPC, CDIP, CCDS, CCS-P, RHIA, RHIT) required
  • Demonstrate knowledge of 1995 and 1997 Evaluation and Management Documentation Guidelines and other professional documentation requirements
  • Minimum of 2-3 years of experience auditing medical charts and coding required
  • Demonstrate advance knowledge of critical care documentation criteria

SKILLS REQUIRED: Must be able to pass E&M skills test

  • Job Knowledge: Understands the expectations of the position and consistently meets the objective of the role
  • Computer experience in word processing and excel

ABILITIES REQUIRED (work characteristics, behaviors, leadership abilities, etc.):

  • Productive: Completes assigned charts and reports correctly and within time allowed
  • Communication: Keeps team informed and promotes open communication
  • Problem Solving/Decision Making: Uses sound judgement to gather and analyze information in accordance with American Physician Partners Policies


  • Travel – light as needed to local facility
  • Ability to sit for long periods of time throughout day
  • Ability to work at a computer for 8+ hours

Apply for this Position

Note: All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

*INTERNAL CANDIDATES: To be considered for an open position, you must be in good standing (i.e., not on a Performance Improvement Plan) and in your current position for at least six months. You must also meet the minimum requirements for the job and be able to perform the essential functions of the position.