Clinical Documentation Integrity Registered Nurse - Full Time
About The Position
In this role you will: Conduct concurrent and retrospective reviews of inpatient and observation medical records to ensure documentation accurately reflects the patient’s clinical condition, acuity, and medical necessity. Identify documentation improvement opportunities related to: Principal and secondary diagnoses Present on Admission (POA) indicators Severity of Illness (SOI) and Risk of Mortality (ROM) Clinical validity and CMS/payer expectations Initiate compliant, well‑supported physician queries following AHIMA and ACDIS guidelines. Collaborate with Coding, HIM, Case Management, Revenue Cycle, and medical staff to ensure complete, accurate, and consistent documentation throughout the record. Provide targeted provider education on documentation requirements, clinical indicators, and specialty‑specific opportunities for improvement. Assist with denial prevention and payer audit response by clarifying documentation and supporting clinical validation reviews. Monitor CDI program performance metrics (e.g., query rate, agreement rate, impact on SOI/ROM, query response rate) and contribute to reporting and analysis. Participate in CDI and documentation-related committees, workgroups, and performance improvement initiatives. Support accurate quality measure abstraction through improved documentation consistency (PSIs, mortality metrics, core measures, risk adjustment elements, etc.). Quality, Regulatory, and Performance Improvement Ensure adherence to all CMS Conditions of Participation (CoPs), CMS documentation requirements, and applicable state and regulatory guidelines. Partner with Quality to provide input for dashboards, metric reporting, and committee presentations as assigned. Support organizational goals related to: Mortality reduction Patient safety Documentation accuracy Denial mitigation and audit readiness Participate in regulatory surveys, mock audits, and internal readiness assessments related to documentation integrity. Promote HRO principles and proactive identification of documentation risks or patterns impacting quality reporting or compliance. OTHER DUTIES Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Requirements
- Graduate of an accredited School of Nursing (ADN or BSN).
- Current Registered Nurse (RN) license in good standing.
- Completion of hospital-required clinical competencies and continuing education.
- Minimum 3 years of acute care clinical experience (ICU, ED, or medical‑surgical strongly preferred).
- Strong understanding of clinical documentation standards, coding principles, and evidence‑based sepsis care.
Nice To Haves
- Bachelor of Science in Nursing (BSN) strongly
- Master’s degree in Nursing, Healthcare Administration, Quality, or related field (preferred but not required).
- Formal training or coursework in: Clinical Documentation Integrity; Quality improvement / performance improvement; High Reliability Organization (HRO) principles desirable
- Prior CDI experience preferred
- Experience in clinical validation or working with Coding/HIM
- Experience with payer audits, utilization review, quality improvement, or risk adjustment concepts preferred
- CCDS – Certified Clinical Documentation Specialist (ACDIS)
- CDIP – Clinical Documentation Improvement Practitioner (AHIMA)
- CPHQ – Certified Professional in Healthcare Quality
- Lean Six Sigma Yellow or Green Belt
Responsibilities
- Conduct concurrent and retrospective reviews of inpatient and observation medical records
- Identify documentation improvement opportunities
- Initiate compliant, well‑supported physician queries
- Collaborate with Coding, HIM, Case Management, Revenue Cycle, and medical staff
- Provide targeted provider education on documentation requirements
- Assist with denial prevention and payer audit response
- Monitor CDI program performance metrics
- Participate in CDI and documentation-related committees, workgroups, and performance improvement initiatives
- Support accurate quality measure abstraction
- Ensure adherence to all CMS Conditions of Participation (CoPs), CMS documentation requirements, and applicable state and regulatory guidelines
- Partner with Quality to provide input for dashboards, metric reporting, and committee presentations as assigned
- Support organizational goals related to mortality reduction, patient safety, documentation accuracy, denial mitigation and audit readiness
- Participate in regulatory surveys, mock audits, and internal readiness assessments related to documentation integrity
- Promote HRO principles and proactive identification of documentation risks or patterns impacting quality reporting or compliance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
251-500 employees
