Ambulatory CDI Specialist

Job Summary

The Ambulatory Clinical Documentation Integrity (CDI) Specialist is responsible for conducting comprehensive prospective and retrospective reconciliation reviews of ambulatory medical records to identify and capture documented and potential Hierarchical Condition Category (HCC) diagnoses and autosuggested conditions impacting HCC coding and Risk Adjustment Factor (RAF) scores. The specialist will query providers to ensure accurate and complete documentation that supports HCC and condition-related diagnoses, ultimately enhancing RAF score accuracy and improving risk adjustment outcomes.

In this role, the CDI Specialist is responsible for facilitating improvement in the overall quality and completeness of medical record documentation on a prospective basis. The CDI Specialist promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients’ severity of illness. The CDI Specialist obtains appropriate clinical documentation through collaborative communications from having developed positive working relationships with physicians, nursing staff, other patient care providers, and the coders. The CDI Specialist is also responsible for providing informal and formal education to all members of the care team regarding clinical documentation.

Minimum Qualifications

Minimum Education: Associate's Degree in Nursing
Minimum Years of Experience: A minimum of 3 years clinical experience in nursing. Preferred experience includes CDI, coding, or risk adjustment experience in ambulatory or acute care setting.
Substitutable Education & Experience: None.
Required Certifications/Licensure: Current Registered Nurse (RN) License;

Certification from either AAPC (Certified Documentation Expert - Outpatient (CDEO) or Certified Risk Adjustment Coder (CRC)) or ACDIS (Certified Clinical Documentation Specialist-Outpatient (CCDS-O)) or AHIMA (Certified Coding Specialist (CCS) or Certified Documentation Improvement Practitioner (CDIP)). Those without one of the listed certifications must obtain one of the listed certifications within 2 Years of entry into the role.
Required Training: None.

Essential Functions

• Validate the accurate assignment of working HCC diagnoses affecting RAF scores within the ambulatory patient population by collaborating with physicians and advanced practice providers.
• Conduct thorough prospective reviews of selected ambulatory patient records, documenting all relevant findings and tracking key information throughout the process.
• Identify areas where documentation requires clarification and engage with physicians, advanced practice providers, and other healthcare professionals to resolve discrepancies.
• Maintain strict confidentiality of patient information and hospital and physician practice data in accordance with privacy regulations.
• Assure all documentation is accurate, complete, and compliant, supporting acute or chronic conditions and medical necessity. This helps improve patient outcomes and supports risk adjustment needs.
• Develop and sustain positive working relationships with providers, advanced practice providers, administrators, and revenue cycle partners to promote the success of the CDI program.

Duties & Responsibilities

• Use strong communication skills to connect CDI workflow and processes, driving results through the ambulatory CDI program.
• Understanding of payment structures, outpatient reimbursement models, and the impact of provider documentation on ICD-10-CM and HCC risk adjustment, ensuring compliance with reporting standards for claims submission.
• Develop presentations for providers individually and in groups to understand the importance of CDI and requirements within the outpatient clinic settings.
• Able to effectively prioritize tasks such as documentation reviews, provider education, and program deadlines.
• Stay up to date with industry standards by participating in internal and external continuing education related to HCC documentation, ICD-10-CM coding, AHA Coding Clinics, and Official Coding Guidelines.
• Utilize software and other technology tools to prioritize tasks, collect and analyze data, and monitor program effectiveness and outcome reporting.
• Perform other duties as assigned.