DeliverHealth is seeking an experienced Clinical Documentation Improvement (CDI) Specialist to support the continuous improvement of InstaNote's AI-powered Clinical Documentation Improvement (CDI) feature.
The primary responsibility of this role is to evaluate the quality, clinical relevance, and accuracy of the CDI recommendations generated by InstaNote during patient encounters. The specialist will validate AI-generated suggestions, identify false positives, false negatives, and missed documentation opportunities, and provide structured feedback to Product Management and Engineering teams to continuously enhance the performance of the CDI engine.
This is not a traditional operational CDI role focused on physician queries or concurrent hospital documentation reviews. Instead, this is a Product Quality and Clinical AIrole that ensures InstaNote delivers clinically meaningful, accurate, and actionable documentation improvement recommendations.
This role serves as the critical link between clinical expertise, revenue cycle knowledge, and AI product development.
JOB DUTIES & RESPONSIBILITIES
Review and validate CDI recommendations generated by InstaNote, including:
Missing diagnoses
Diagnosis specificity
HCC and Risk Adjustment opportunities
CC/MCC opportunities
Medical necessity documentation
Procedure documentation
Severity of Illness (SOI)
Risk of Mortality (ROM)
Missing clinical details
Documentation clarification opportunities
Quality measure documentation
Chronic condition documentation
Medication-related documentation opportunities
For each recommendation, determine whether it is:
Clinically accurate
Relevant to the encounter
Supported by documentation
Actionable for the provider
High value from a coding and reimbursement perspective
Evaluate clinical notes generated by InstaNote to determine whether:
Important diagnoses are missing
Documentation lacks clinical specificity
Medical decision-making is adequately represented
History, assessment, and plan support the documented diagnoses
Clinical evidence aligns with suggested CDI opportunities
Identify documentation gaps that the AI failed to recognize.
Conduct routine audits of the CDI feature by measuring:
Recommendation accuracy
Precision
Recall
False positive rate
False negative rate
Missed documentation opportunities
Clinical relevance
Specialty appropriateness
Provider usability
Recommendation acceptance potential
Document findings in standardized quality scorecards.
Partner closely with Product Management and Engineering teams by providing structured feedback on:
Incorrect recommendations
Missing clinical logic
New documentation scenarios
Specialty-specific documentation patterns
Prompt improvements
Knowledge gaps
AI workflow enhancements
User experience improvements
Recommendation prioritization
Participate in regular AI quality review sessions to prioritize enhancements.
Support AI model development by creating and maintaining:
Gold-standard annotated clinical cases
Specialty-specific documentation examples
Accepted and rejected recommendation libraries
Clinical review guidelines
Evaluation datasets for regression testing
Reference documentation standards
Review CDI recommendations across specialties such as:
Orthopedics
Emergency Medicine
Urgent Care
Primary Care
Cardiology
Internal Medicine
Behavioral Health
Pediatrics
Surgical Specialties
Recommend specialty-specific enhancements to improve AI performance.
Collaborate with:
Product Managers
AI Engineers
Prompt Engineers
Machine Learning Engineers
Medical Coders
Clinical Informaticists
QA Engineers
Data Scientists
Translate clinical observations into clear product requirements and acceptance criteria.
Key Deliverables
Weekly AI CDI validation reports
Clinical quality scorecards
False positive and false negative analyses
Missed opportunity reports
Root cause analyses
Product enhancement recommendations
Annotated reference cases
Specialty-specific feedback reports
Monthly AI performance trend reports
Clinical acceptance criteria for new CDI features
KNOWLEDGE, SKILLS, & ABILITIES
Technical Knowledge
Strong understanding of:
Clinical Documentation Improvement
ICD-10-CM
HCC Risk Adjustment
CPT coding fundamentals
Documentation specificity
Medical necessity
Clinical terminology
Provider documentation workflows
AI-assisted documentation tools
Electronic Health Records (Epic, athenahealth, Cerner, eClinicalWorks, etc.)
Core Competencies
Strong clinical judgment
Excellent analytical skills
Attention to detail
Ability to identify documentation gaps
Root cause analysis
Data-driven decision making
Effective written communication
Cross-functional collaboration
Continuous improvement mindset
Passion for healthcare AI and clinical innovation
Bachelor's degree in Nursing, Health Information Management, Medicine, Physician Assistant Studies, or a related clinical field.
5+ years of Clinical Documentation Improvement experience.
Experience reviewing physician documentation for coding quality and documentation completeness.
Strong knowledge of ICD-10-CM coding principles.
Experience with HCC and Risk Adjustment documentation.
Familiarity with outpatient and ambulatory documentation practices.
Experience working with physicians on documentation quality initiatives.
Exposure to AI-assisted clinical documentation solutions is preferred.
Preferred credentials include:
RN / BSN
RHIA
RHIT
PA
NP
MD / DO (preferred but not required)
DeliverHealth operates InstaNote, an AI-powered clinical documentation improvement (CDI) platform designed to enhance the quality and accuracy of clinical notes during patient encounters. The company focuses on helping healthcare providers identify missing diagnoses, improve documentation specificity, and capture valuable clinical details that impact coding, reimbursement, and quality measures. InstaNote's CDI engine analyzes clinical documentation to recognize opportunities for better coding accuracy, risk adjustment, and medical necessity documentation. DeliverHealth positions itself at the intersection of clinical expertise and AI product development, working to ensure that healthcare documentation is clinically meaningful, accurate, and actionable for providers.
