Position Overview

Position - Clinical Documentation Integrity (CDI) Specialist

Experience - 6+ years of relevant qualified experience

Primary Domain - Inpatient CDI and medical coding

Education / Background - Nursing, Allied Health, Health Information Management, Medical Coding, or another closely related healthcare discipline with hospital-based experience

Role Focus - Clinical documentation review, coding collaboration, provider engagement, education, and documentation quality

Added Advantage - CDI SME, educator/trainer, auditor/quality reviewer, mentor, or team-lead experience

Role Summary

We are seeking an experienced Clinical Documentation Integrity (CDI) professional with 6+ years of relevant experience in an inpatient healthcare environment. The ideal candidate will combine a strong clinical or hospital-based foundation with practical expertise in inpatient medical coding and clinical documentation.

The CDI Specialist will review inpatient medical records to identify clinically supported documentation opportunities, promote accurate and complete representation of the patient's condition and care, collaborate with providers and coding teams, and contribute to documentation quality and education initiatives.

Key Responsibilities

- Perform concurrent and/or retrospective CDI reviews of inpatient medical records in accordance with organizational policies and applicable coding and documentation standards.
- Identify clinical indicators, diagnoses, severity/risk factors, complications, comorbidities, and other documentation opportunities requiring clarification or greater specificity.
- Review the medical record holistically, including provider documentation, nursing documentation, consultation notes, diagnostic reports, laboratory results, medications, procedures, and treatment plans.
- Initiate appropriate, compliant, non-leading physician queries when the medical record contains clinically supported opportunities for clarification.
- Collaborate with physicians, advanced practice providers, nurses, medical coders, utilization review teams, quality teams, and other stakeholders.
- Support accurate capture of diagnoses, present-on-admission status, severity of illness, risk of mortality, and other relevant documentation elements.
- Apply inpatient coding concepts, ICD-10-CM/PCS principles, Official Guidelines for Coding and Reporting, and CDI best practices.
- Recognize documentation and coding inconsistencies and communicate them through appropriate CDI/coding workflows.
- Support documentation improvement while maintaining clinical integrity and avoiding unsupported diagnoses.
- Track CDI opportunities, query outcomes, physician response patterns, and assigned productivity/quality metrics.
- Participate in audits, case reviews, peer reviews, and process improvement activities.
- Stay current with changes in coding guidelines, CDI standards, regulatory requirements, clinical terminology, and reimbursement methodologies.
- Contribute to CDI education and knowledge-sharing initiatives.

Core Knowledge & Competencies

- Strong inpatient clinical documentation review skills.
- Working knowledge of inpatient medical coding and ICD-10-CM/PCS concepts.




- Ability to connect clinical indicators with provider documentation and coding implications.
- Understanding of principal diagnosis, secondary diagnoses, complications/comorbidities, and present-on-admission concepts.
- Understanding of severity of illness (SOI), risk of mortality (ROM), and clinical validation concepts.
- Knowledge of common inpatient medical and surgical conditions and treatment pathways.
- Ability to interpret laboratory, diagnostic imaging, medication, procedure, and treatment information.
- Strong clinical reasoning and medical terminology skills.
- Ability to distinguish clinically supported documentation opportunities from unsupported or non-compliant opportunities.
- Strong written and verbal communication skills for provider interaction and compliant query communication.
- Strong attention to detail, analytical ability, and record-review discipline.

Required Qualifications

- Minimum 6 years of relevant experience in inpatient CDI, inpatient coding, clinical documentation, hospital operations, or a closely related healthcare environment.
- Education in Nursing, Allied Health, Health Information Management, Medical Coding, Life Sciences, or another relevant healthcare discipline.
- Strong hands-on experience with inpatient CDI and/or inpatient medical coding workflows.
- Strong understanding of inpatient medical records and clinical documentation.
- Demonstrated ability to review complex inpatient cases and identify documentation opportunities.
- Working knowledge of ICD-10-CM/PCS and inpatient coding principles.
- Ability to communicate professionally with physicians, clinical staff, coders, and other stakeholders.
- Strong analytical, documentation, and problem-solving skills.

Preferred Educational Background

Bachelor's degree or equivalent qualification in Nursing, Allied Health, Health Information Management, Medical Coding, Life Sciences, or a related healthcare discipline is preferred. Equivalent hospital-based clinical or healthcare experience may be considered depending on the candidate's CDI and inpatient coding expertise.

Preferred Certifications / Credentials

- CCDS or another recognized CDI credential.
- CCDS-Inpatient or comparable CDI certification.
- CCS, CIC, or equivalent recognized coding credential.
- RN or other relevant clinical professional credential, where applicable.

Added Advantage

- Prior experience as a CDI Subject Matter Expert (SME).
- CDI trainer, educator, mentor, or quality/audit reviewer experience.
- Experience developing CDI training material, case studies, competency assessments, or onboarding programs.
- Experience conducting CDI audits, peer reviews, quality reviews, and feedback sessions.
- Experience handling complex or high-risk inpatient cases.
- Experience supporting CDI process improvement, workflow optimization, or technology-enabled CDI programs.




- Experience with CDI/coding software, electronic health records, encoder systems, or clinical documentation technology.
- Team-lead or supervisory experience within CDI, coding, or clinical documentation functions.

Clinical Case Exposure

- Sepsis and severe infection
- Acute respiratory failure and other respiratory conditions
- Acute kidney injury and renal conditions
- Heart failure and cardiovascular conditions
- Acute coronary syndrome and myocardial infarction
- Encephalopathy and neurological conditions
- Stroke and cerebrovascular conditions
- Shock and other critical care conditions
- Malnutrition and nutritional conditions
- Acute blood loss anemia and other clinically significant anemia
- Postoperative complications and other complications of care
- Electrolyte and metabolic disorders
- Complex surgical cases
- Multiple comorbidities and medically complex patients

Performance Expectations

- Consistently perform accurate and thorough inpatient chart reviews.
- Identify clinically supported documentation opportunities with appropriate prioritization.
- Maintain compliant and clinically supported physician query practices.
- Demonstrate strong collaboration with coding and clinical teams.
- Meet established productivity, quality, turnaround-time, and documentation standards.
- Contribute to education, audit, quality improvement, and knowledge-sharing activities.
- Maintain confidentiality and adhere to applicable privacy, compliance, and organizational requirements.

Professional Competencies

- Clinical judgment and analytical thinking
- Attention to detail
- Professional communication
- Provider engagement and collaboration
- Integrity and ethical decision-making
- Time management and prioritization
- Adaptability to changing CDI/coding requirements
- Coaching and knowledge-sharing mindset
- Ownership and accountability
- Ability to work effectively in a multidisciplinary environment

Ideal Candidate Profile The ideal candidate is an experienced inpatient CDI professional who combines a strong clinical or hospital-based foundation with practical knowledge of inpatient medical coding and documentation requirements. The candidate should be able to independently review complex charts, recognize clinically meaningful documentation opportunities, communicate effectively with providers and coding teams, and support a culture of accurate, complete, and compliant clinical documentation.

Candidates who have progressed into SME, educator, trainer, auditor, quality reviewer, or team-lead responsibilities are especially well suited to a senior-level CDI environment.

Suggested Interview Focus Areas

- Inpatient chart review and identification of documentation opportunities.
- Clinical indicators versus provider documentation.
- Query appropriateness, compliance, and non-leading query construction.
- ICD-10-CM/PCS and inpatient coding fundamentals.
- Principal diagnosis and secondary diagnosis concepts.
- SOI/ROM and clinical validation concepts.
- Complex inpatient case scenarios.
- Provider communication and query follow-up.
- CDI productivity, quality, and audit methodology.
- Training, SME, mentoring, or leadership experience.

📌 Clinical Documentation Integrity (CDI) Specialist (India)
🏢 Bulwark Health
📍 India