Clinical Document Integrity (CDI) Specialist

We are looking for a Clinical Document Integrity (CDI) Specialist to join a healthcare organization in Sacramento, California on a Contract basis. In this role, you will strengthen the quality and completeness of clinical records through detailed chart review, collaboration with providers, and application of documentation and coding standards. This position plays an important part in supporting accurate clinical representation, compliant reporting, and reliable outcomes across assigned service areas.

Responsibilities:
• Conduct concurrent and retrospective reviews of inpatient and outpatient records to identify documentation gaps and improve the clarity of the clinical story.
• Evaluate charts early in the patient stay and continue follow-up reviews to confirm that clarification requests are addressed in the medical record.
• Apply established coding guidance, reimbursement rules, and regulatory standards to support accurate capture of diagnoses, procedures, severity of illness, and risk indicators.
• Work closely with coding professionals to align clinical documentation with diagnostic and procedural data needed for complete and compliant record submission.
• Communicate with physicians and other clinical staff to obtain precise documentation that reflects the level of care provided and the patient’s condition.
• Serve as a documentation integrity resource for assigned departments or service lines, offering education and practical guidance on documentation expectations.
• Track trends, identify recurring documentation issues, and recommend process improvements that enhance record quality and provider workflow.
• Maintain effective partnerships with clinical teams and leadership to support documentation strategies, compliance efforts, and quality reporting initiatives.

Qualifications:

• Clinical experience with strong knowledge of medical record review, documentation standards, and coding principles.
• Ability to interpret healthcare regulations, compliance requirements, and reimbursement-related documentation guidelines.
• Strong written and verbal communication skills with the ability to work effectively with providers, coders, and operational teams.
• Experience performing audits, quality reviews, reporting, and documentation analysis in a healthcare setting.
• Proficiency in data entry, spreadsheets, and office-based systems used for tracking, research, and reporting.
• Ability to manage priorities independently, maintain timelines, and support multiple assignments across service lines.
• Knowledge of policy, procedures, and documentation practices that support accurate and compliant clinical records.

Compensation

$40.00-$65.00 Hourly

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