Summary

The Clinical Documentation Improvement (CDI) Specialist – Professional Billing supports accurate, compliant professional fee billing through focused review and improvement of provider documentation. This role partners closely with physicians, advanced practice providers (APPs), professional coders, and revenue cycle stakeholders to ensure documentation fully supports CPT, HCPCS, ICD 10 CM codes, modifier usage, and medical necessity.

The CDI Specialist serves as a documentation and coding subject matter expert, emphasizing education, collaboration, and prevention of downstream denials or compliance risk, rather than claim production volume.

Job Duties

Professional Documentation Review

• Reviews outpatient, clinic, procedural, and surgical professional documentation to identify gaps impacting coding accuracy and compliance.
• Ensures documentation supports E/M level selection, procedure complexity, modifier use, and payer medical necessity requirements.
• Identifies documentation trends that may result in down coding, denials, or audit exposure.

Provider Query & Education

• Initiates compliant provider queries to clarify diagnoses, procedures, clinical intent, and E/M components.
• Provides case based and trend based education to physicians and APPs focused on professional documentation best practices.
• Serves as a trusted advisor to providers regarding documentation requirements for professional billing.

Coding & Revenue Cycle Collaboration

• Collaborates with professional coders to ensure documentation supports accurate CPT, HCPCS, ICD 10 CM, and modifier assignment prior to claim submission.
• Partners with revenue integrity, denials, and compliance teams to resolve documentation related issues.
• Supports initiatives to improve first pass yield and reduce rework and payer recoupments.

Audit, Compliance & Quality Improvement

• Supports internal and external audits by validating documentation support for billed professional services.
• Tracks and trends documentation issues, provider response rates, and improvement opportunities.
• Participates in continuous improvement initiatives related to documentation standards and professional billing workflows.
• Performs other job-related duties as assigned.

Minimum Qualifications

• High School diploma or GED.
• Four years of relevant experience.
• Certified Professional Coder (CPC) or Certified Inpatient Coder (CIC) through the American Academy of Professional Coders (AAPC); or Certified Coding Specialist – Physician-based (CCS-P), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) through the American Health Information Management Association (AHIMA).

Preferred Qualifications

• Experience in professional fee CDI, professional coding, auditing, or revenue integrity.
• Clinical background (RN, LPN, MA, or allied health).
• Experience in a multi specialty or academic practice plan.
• Familiarity with payer policies, NCCI edits, and modifier driven denials.
• CDI Certification.