CDI Practitioner

Job Title: CDI Practitioner

Department: Health Information Management (HIM)

Reports To: CDI Section Lead / HIM Manager

Role Purpose:

The Clinical Documentation Improvement (CDI) Practitioner is responsible for reviewing clinical documentation across inpatient, outpatient, and emergency records to ensure clarity, accuracy, and specificity of diagnoses and procedures. This role supports accurate coding, data reporting, and regulatory compliance by collaborating closely with physicians, coders, and medical staff to improve documentation quality. The CDI Practitioner plays a key role in enhancing patient care data integrity and driving hospital-wide performance indicators.

Key Responsibilities:

Clinical Documentation Review

• Perform daily reviews of patient records (IP/OP/ER) to identify gaps or inconsistencies.

• Ensure documentation supports the highest level of specificity for diagnoses and procedures.

• Understand and interpret clinical language to assess documentation adequacy.

Query and Provider Engagement

• Develop and submit ethical, compliant physician queries to clarify ambiguous or conflicting data.

• Follow up on outstanding queries and ensure timely documentation responses in medical records.

• Educate providers on the importance of clinical documentation for data integrity and patient outcomes.

Data Reporting and Education

• Analyze CDI metrics and contribute to performance improvement initiatives.

• Present findings, trends, and educational materials to clinicians and HIM staff.

• Assist with audits and regulatory data submission when required.

Compliance and Collaboration

• Ensure all documentation practices align with MOH, SHC, CHI, and hospital policies.

• Collaborate with coding, RCM, and other clinical departments to promote unified documentation standards.

• Maintain strict confidentiality and uphold professional and ethical standards in all CDI activities.

Skills & Qualifications

Essential Minimum Requirements:

• Graduate in a medical-related field (e.g., Nursing, HIM, Therapist, or Coding Program)

• Certified Clinical Documentation Practitioner/Specialist (local or international certification)

Desired Experience and Education:

• 1–2 years of experience in clinical auditing or documentation review within a hospital setting

• Bachelor’s degree in nursing or Allied Health preferred

• Additional certification in clinical coding or documentation auditing is an advantage

Technical Competencies:

• Strong understanding of clinical terminology and ICD documentation principles

• Proficient in interpreting health records and data trends

• Ability to develop professional queries using standardized language

• Effective presentation, communication, and report-writing skills

• Collaborative mindset with high ethical standards