Learn what skills and qualities interviewers are looking for from a clinical documentation improvement specialist, what questions you can expect, and how you should go about answering them.
Clinical documentation improvement (CDI) specialists are responsible for ensuring the accuracy and completeness of medical records. They work with physicians, nurses, and other clinical staff to make sure all the necessary information is included in patient charts. CDI specialists also work with insurance companies to make sure they have all the information they need to process claims.
If you’re looking for a job in CDI, you’ll likely face some common interview questions. To help you prepare, we’ve gathered some of the most common CDI interview questions and provided sample answers.
The interviewer may ask this question to gauge your knowledge of the coding system and how it relates to clinical documentation improvement. Use your answer to highlight any experience you have with ICD-10 coding, including what it is and how it’s used in healthcare settings.
Example: “Yes, I am familiar with the 2015 ICD-10 medical coding system. In my last role as a clinical documentation improvement specialist, I worked closely with physicians and other staff members to ensure that all patient records were coded correctly using ICD-10 standards. This helped me identify areas where we could improve our documentation practices so that we could accurately code patient information for billing purposes.”
This question can help the interviewer determine if you have the skills and qualifications to succeed in this role. Use your answer to highlight some of your most important skills, such as attention to detail, organizational skills, problem-solving skills and communication skills.
Example: “I think one of my strongest skills is my ability to communicate with patients and medical professionals. I am always sure to ask questions when I need more information about a patient’s condition or treatment plan so that I can accurately document everything in their record. Another skill I rely on for this job is my organization skills. I keep detailed notes throughout each day so that I can easily find what I’m looking for later.”
The interviewer may want to know how you will work with others in the department and across departments to achieve your goals. Showcase your communication skills, ability to collaborate and willingness to help others succeed.
Example: “I would first meet with each member of the team to learn more about their roles and responsibilities. I would then create a plan for improving documentation accuracy by implementing new processes and procedures that are easy to understand and implement. For example, I might develop a checklist or template for recording patient information that can be used throughout the entire hospital.”
EHRs are electronic health records, which are a type of software that allows healthcare professionals to document patient information. The interviewer may ask this question to learn more about your experience with EHRs and how you’ve used them in the past. In your answer, try to explain what an EHR is and describe your experience using one.
Example: “I have worked as a nurse for five years now, and I’ve always used EHRs. When I first started working as a nurse, I was still getting used to using EHRs, but over time, I became very comfortable with it. Now, I find it much easier to use than paper charts because I can access my patient’s information from anywhere.”
This question can help the interviewer assess your problem-solving skills and ability to resolve issues in a timely manner. Use examples from your previous experience that highlight your critical thinking, communication and organizational skills.
Example: “In my last role as a clinical documentation improvement specialist, I noticed an issue with one of my patient’s records where they were listed under two different names. This was due to a clerical error when entering their information into the system. I immediately contacted the nurse who entered the data to confirm if she had made a mistake or if there was another reason for this discrepancy. She confirmed it was a mistake and updated the record accordingly. I then notified the physician so he could correct his notes.”
Interviewers may ask this question to assess your conflict resolution skills. When answering, it can be helpful to describe a specific situation and how you would handle it.
Example: “If a patient had a negative experience with a doctor, I would first listen to their concerns and then try to resolve the issue as quickly as possible. If they wanted to speak with a supervisor, I would explain that our supervisors are not available for phone calls but that we have an escalation process in place if there is ever a problem. I would also offer to connect them with someone else who could help.”
This question can help the interviewer assess your problem-solving skills and ability to adapt to challenging situations. Your answer should show that you are willing to take responsibility for finding solutions, rather than making excuses or blaming others.
Example: “I would first try to contact the patient’s doctor to find out why the records were not available. If I could not reach them, I would ask my manager if there was a way to get the records before the appointment. If neither of these options worked, I would reschedule the appointment so that it did not interfere with other patients who had their medical records on time.”
HIPAA, or the Health Insurance Portability and Accountability Act of 1996, is a federal law that protects patients’ privacy. It also requires healthcare providers to keep records confidential and safe from unauthorized access. An interviewer may ask this question to make sure you understand HIPAA regulations and how they apply to your role as a clinical documentation improvement specialist. In your answer, try to show that you have a solid understanding of HIPAA’s requirements and can follow them effectively.
Example: “I am very familiar with HIPAA regulations because I worked in a hospital setting for several years. As a result, I know that it’s important to protect patient information and ensure that all staff members are following HIPAA guidelines when handling medical records. I would always be careful about what information I shared with others and would never share any patient information without their permission.”
This question can help the interviewer determine if you have experience with a paper-based system and how well you adapt to new technology. Your answer should include your previous experience working with paper records, as well as any challenges you faced while using them.
Example: “I do have some experience working with paper medical records. However, I prefer electronic systems because they are more efficient and allow me to enter data faster than when I was entering information into a paper record. In my last role, we were still using paper records, so I had to work quickly to ensure that all of the patient’s information was entered correctly before it was scanned into our electronic system.”
An interviewer may ask this question to assess your leadership skills and ability to collaborate with others. When answering, it can be helpful to mention a specific example of how you defined the roles of other team members in a previous role.
Example: “When working with a team, I always make sure that everyone understands their own responsibilities as well as those of their colleagues. In my last position, for instance, I noticed that one of my coworkers was spending too much time on patient documentation while another coworker had not been documenting enough information about patients’ care plans. So, I met with both employees separately to discuss their roles and expectations. After our meetings, they both understood what they needed to do and were able to work together more effectively.”
The FDA is the Food and Drug Administration, a federal agency that regulates food safety. The FDA also regulates medical devices, prescription drugs and blood products. This question helps employers understand your knowledge of regulations and how you would apply it to their organization.
Example: “I have experience working with the FDA as part of my previous role. I know there are several regulations they enforce, including the Safe Medical Devices Act, the Prescription Labeling Rule and the Unique Device Identification System. These rules help ensure patient safety by ensuring healthcare providers comply with quality standards for documentation.
In my last position, we had an issue where our electronic health record system didn’t meet the requirements of the Unique Device Identification System. We worked closely with our IT department to update our software so we could continue providing safe care to patients.”
The interviewer may ask you to describe your process for conducting a quality control check on medical records. This question can help the interviewer understand how you apply your knowledge of coding and documentation standards to ensure accurate patient record keeping. In your answer, try to explain your steps in detail so that the interviewer can see how you would perform this task efficiently.
Example: “I always start by reviewing the physician’s notes first. I then review the nursing notes to make sure they are consistent with the physician’s notes. Next, I look at the diagnostic codes to make sure they match up with the patient’s symptoms and test results. Finally, I compare all of these elements against the hospital’s coding guidelines to make sure everything is correct.”
Employers ask this question to learn more about your qualifications for the role. They want someone who is passionate about improving patient care and outcomes, as well as committed to their organization’s mission. When preparing your answer, think of what makes you a good fit for the position. Consider highlighting any relevant experience or skills that make you qualified for the job.
Example: “I am an ideal candidate for this position because I have extensive knowledge of medical terminology and coding systems. In my previous role, I worked with physicians to improve documentation quality by ensuring all information was accurate and consistent. This helped doctors provide better care for patients while also reducing costs associated with inaccurate documentation.”
The interviewer may ask this question to determine your level of experience with specific software programs. If you have previous experience working as a clinical documentation improvement specialist, the interviewer may want to know which medical software programs you used in your past role. You can answer this question by listing the software programs you are familiar with and how much experience you have using them.
Example: “I am very familiar with Meditech and Epic Systems because I worked for a hospital that used both systems. In my current position, we use Cerner, so I’m still learning about it but feel comfortable using most features. I also have some experience with MEDITECH and PHINCTOC.”
The interviewer may ask this question to assess your knowledge of the medical record and how you use it. Your answer should show that you understand what information is most important for a patient’s health care team to have access to when they need it.
Example: “I think the most important aspect of a patient’s medical record is their current diagnosis, because without knowing what condition they are currently experiencing, it can be difficult to provide them with appropriate treatment. I also think it is important to include any test results or other relevant information that supports the diagnosis so that there is no confusion about the patient’s current state.”
This question can help the interviewer assess your knowledge of medical record keeping and how you apply it to patient care. Your answer should demonstrate that you understand the importance of accurate documentation and when it’s necessary to update records.
Example: “I believe that medical records should be updated as often as needed, but I also think there are times when updating them too frequently may not be beneficial. For example, if a patient is in the hospital for an extended period of time, I would want to wait until they’re discharged before updating their records. However, if a patient has multiple appointments or procedures within a short period of time, I would update their records after each visit or procedure so that all information is current.”
The interviewer may ask you a question like this to evaluate your ability to handle challenging situations. Use examples from past experience where you used critical thinking skills and problem-solving techniques to resolve discrepancies between patient reports and clinical documentation.
Example: “I once worked with a patient who reported symptoms that were not reflected in their medical records. I asked the patient if they had experienced any other symptoms, which led them to report those symptoms. The patient then told me about another symptom they had been experiencing but did not report because it was unrelated to their primary complaint. This information helped me update the patient’s record so that future clinicians could better understand the patient’s condition.”
