Job Title: Physician Advisor for Clinical Documentation Integrity
GENERAL SUMMARY:
The Physician Advisor for CDI is a board-certified physicianwho serves as the clinical leader and liaison between the CDI department, physicians, and coding/billing teams. This role is responsible for ensuring that clinical documentation accurately reflects the complexity of patient care, supports optimal reimbursement, and complies with regulatory standards. The ideal candidate will have a strong background in clinical practice, excellent communication skills, and a passion for improving documentation quality across the organization.
This role offers a unique opportunity to leverage clinical expertise to drive improvements in documentation quality and revenue optimization while playing a pivotal role in enhancing patient care outcomes.
PRINCIPAL DUTIES AND RESPONSIBILITIES
Clinical Documentation Improvement:
• Analyze patient medical records to identify areas where documentation needs improvement, including missing diagnoses, unclear clinical findings, or inconsistencies in treatment plans to ensure accurate representation of diagnoses, procedures, and severity of illness
• Provide clinical expertise and guidance to CDI specialists and coders in clarifying documentation issues
• Identify opportunities to enhance documentation to support the level of care provided
• Participate in interdisciplinary case reviews and CDI meetings to drive process improvements
• Work collaboratively with medical staff to ensure documentation accurately reflects the severity of illness, risk of mortality, and complexity of care
Physician and Staff Education:
• Educate physicians and advanced practice providers (APPs) on best practices in clinical documentation and coding compliance.
• Coordinate with GME to provide focused education on early development of documentation best practices to incoming residents and fellows
• Serve as a resource for providers regarding clinical terminology, coding nuances, and regulatory requirements
• Provide ongoing feedback and coaching to enhance documentation practices and compliance
• Conduct physician outreach sessions to address common documentation issues and promote awareness of CDI initiatives
Query Support and Review:
• Assist in the development and refinement of compliant physician queries to attending physicians when clarification is needed on clinical details to ensure accurate coding.
• Interpret physician responses and collaborate with the CDI team to resolve any documentation discrepancies.
• Provide feedback on query responses and encourage a culture of accurate, thorough documentation.
• Participate in mortality reviews, DRG downgrade denials management, and clinical validation processes.
Compliance and Quality Alignment:
• Ensure clinical documentation aligns with coding guidelines, CMS regulations, and hospital policies.
• Support hospital initiatives related to compliance, audit readiness, and quality reporting metrics.
• Participate in CDI-related committees and performance improvement initiatives.
• Collaborate with quality teams on initiatives related to hospital-acquired conditions (HACs), patient safety indicators (PSIs), and mortality reviews.
• Contribute to hospital-wide efforts to improve revenue integrity and performance benchmarks.
Data Analysis and Performance Improvement:
• Stay abreast of changes in coding standards (ICD-10-CM, CPT), CMS guidelines, and DNV requirements, and communicate their implications to clinical teams.
• Monitor and analyze CDI metrics such as LOS and GMLOSvariance, Case Mix Index (CMI), and MCC/CC capture rate
• Prepare regular reports on CDI outcomes, including recommendations to optimize reimbursement and clinical quality.
• Collaborate with hospital leadership to implement CDI strategies that improve documentation and patient outcomes.
KNOWLEDGE AND SKILLS REQUIRED:
• Demonstrated interest or experience in clinical documentation improvement, coding, or revenue cycle management.
• Knowledge of CDI principles, coding guidelines (ICD-10-CM, ICD-10-PCS), MS-DRG assignment, and CMS regulations.
• Excellent analytical, communication, and interpersonal skills.
• Ability to work collaboratively with diverse teams, including physicians, CDI professionals, and hospital administration.
KNOWLEDGE AND SKILLS PREFERRED:
● Familiarity with electronic health record (EHR) systems and CDI software is a plus
● Prior experience working directly with a CDI program.
● Advanced training or certification in CDI, medical coding, or healthcare compliance.
● Experience in conducting educational programs for clinical staff.
● Experience with data analysis and performance improvement initiatives.
● Certification by ABQAURP or ACPA
EDUCATION AND EXPERIENCE REQUIRED:
● MD or DO degree with board certification in a clinical specialty.
● Unrestricted Florida state medical license
● A minimum of 3–5 years of clinical practice experience, preferably in an acute care or hospital setting.
EDUCATION AND EXPERIENCE PREFERRED:
● Master’s degree in Business or Healthcare Administration
● Two (2) years or greater experience as a Physician Advisor ● Healthcare Quality and Management Certification (HQCM)or ACPA-C
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Physician-Internal Medicine
Employment Type: Full-Time
Telemedicine : No 
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