CDI Specialist-Coder

Job Title: CDI Specialist – Coder
Employment Type: Full-Time
Starting Pay: $23.00 per hour

Position Summary

The CDI Specialist – Coder is a certified coding professional responsible for conducting real-time, retrospective, and incident-driven audits of clinical documentation to ensure it supports established standards, including medical necessity, CPT/HCPCS, and ICD coding accuracy.

This position collaborates closely with clinical, Health Information Management (HIM), and billing teams to improve the quality and clarity of documentation. Through auditing, education, and query processes, the CDI Specialist – Coder helps ensure accurate coding, regulatory compliance, reporting integrity, and improved patient care outcomes.

Duties and Responsibilities

Coding and Documentation Integrity

• Apply ICD-10-CM, CPT, and HCPCS coding guidelines accurately, ensuring correct assignment of primary and secondary diagnoses, procedures, and modifiers across all levels of care.

• Accurately abstract data from provider documentation for CPT/Evaluation and Management (E/M) code assignment at the outpatient level of care.

• Conduct real-time, retrospective, and incident-driven audits of clinical documentation to validate alignment with established standards, medical necessity, and coding requirements.

• Identify inconsistencies, unclear entries, or documentation gaps and initiate professional provider queries to clarify documentation.

Quality Improvement and Compliance

• Support corrective action planning and track improvements through follow-up reviews.

• Contribute to the development of documentation standards, training priorities, and agency-wide quality initiatives.

• Track and monitor key Documentation and Data Integrity (DDI) metrics, including query response rates, capture rates, and correct primary diagnosis alignment.

• Ensure coding and documentation practices comply with organizational policies, payer requirements, and state and federal regulations.

• Maintain strict confidentiality and professional standards when handling patient information.

Education and Collaboration

• Deliver educational programs for Licensed Medical Practitioners (LMPs), medical staff, and clinical teams on documentation best practices, coding requirements, and CDI/DDI principles.

• Support ongoing staff learning to improve documentation quality and compliance across clinical disciplines.

• Work closely with HIM, coding, and clinical teams to resolve documentation and coding issues.

• Communicate clearly and professionally with staff to facilitate continuous documentation improvement.

Professional Development

• Maintain ongoing professional development by engaging with professional coding organizations.

• Stay current with coding updates, regulatory changes, and industry best practices.

• Investigate complex coding applications and provide guidance to clinical, billing, and operational teams when needed.

Additional Responsibilities

• Perform other duties as assigned.

Professional Requirements

• Demonstrated knowledge of confidentiality principles and risks associated with processing personal health information.

• Proficiency in word processing, spreadsheets, databases, Adobe Pro, and Help Desk ticketing systems.

• Ability to function effectively independently and as part of a team while following instructions.

• Strong judgment and decision-making skills, including knowing when to seek assistance.

• Ability to accurately record, process, and organize large volumes of detailed information.

• Strong professional boundaries and ability to manage confidential and sensitive information appropriately.

• Effective written, verbal, and phone communication skills with individuals at all organizational levels.

• Demonstrated acceptance and respect for diverse lifestyles, cultures, and behaviors.

Qualifications

Minimum Qualifications

• Current Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification.

• Strong knowledge of ICD-10-CM, CPT, and HCPCS coding guidelines.

• Understanding of Clinical Documentation Improvement (CDI) principles and standards.

• Familiarity with state and federal regulations, payer requirements, and compliance standards.

• Strong analytical, organizational, and communication skills.

• High School Diploma or equivalent required.

• Two years of Health Information Management (HIM) college-level coursework preferred.

Preferred Experience

• Experience in behavioral health or pediatric healthcare settings.

• Experience auditing clinical documentation for coding accuracy, compliance, and medical necessity.

• Experience with electronic health record (EHR) systems and coding software.

Certificates, Licenses, and Registrations

• Required: CPC, CCS, or other relevant coding credential.

• Must maintain a valid driver’s license and an acceptable driving record if authorized to use a personal vehicle for agency business.

• When applicable, employee must maintain personal automobile insurance.

Job Knowledge and Skills

• Knowledge of established office procedures, policies, and healthcare regulations.

• Ability to manage highly sensitive and confidential information.

• Strong computer skills, including word processing, spreadsheets, and data entry.

• Experience with electronic health records (EHR) and medical terminology.

• Excellent organizational, customer service, and teamwork skills, with the ability to work independently under supervision.

Compensation & Benefits:

• Full-time 40 hours per week schedule.
• Comprehensive employer-paid healthcare benefits for eligible employees
• 401k with 6% match
• Generous vacation and sick leave
• A supportive team environment dedicated to equity, compassion, and high-quality care.

If you are ready to make a meaningful impact in the lives of children and families—and grow your career along the way—we’d love to hear from you.

If you are ready to make a meaningful impact in the lives of children and families—and grow your career along the way—we’d love to hear from you.

To take a behind-the-scenes look at our programs please visit our website at www.trilliumfamily.org/.