Clinical Documentation Specialist Inpatient

Children's of Alabama • Birmingham, AL

3d

About The Position

The Inpatient Clinical Documentation Integrity (CDI) Specialist Nurse provides clinically based concurrent and retrospective reviews of inpatient medical records to help ensure accurate and complete documentation of patients’ diagnoses, procedures, conditions, treatments, and interventions. The role supports documentation that accurately reflects quality of care, severity of illness, mortality risk, and risk adjustment factors, as well as appropriate coding, reimbursement, and quality initiatives.

The specialist works with leadership, subject matter experts, and operational stakeholders to support compliance with state and federal regulatory codes and guidelines. The CDI department is part of the Revenue Cycle and supports clinical excellence, regulatory compliance, and financial sustainability through documentation review and education for physicians and clinical staff.

The position is full-time, on the day shift from 8:00 a.m. to 4:30 p.m., at Main Campus Lee Building.

Requirements

• Current RN or LPN licensure in the State of Alabama is required; Registered Nurse is preferred.
• At least five years of nursing experience is required, including three years in an acute or intensive care setting.
• A Bachelor of Science in Nursing or an Associate of Science in Nursing is required.
• Alabama RN single-state licensure or an equivalent listed multistate RN qualification is required.
• Five years of staff-level nursing experience with an acute specialization is listed as an essential equivalent qualification.

Nice To Haves

• Pediatric experience is preferred; CDI experience may be considered in lieu of pediatric experience.
• CCDS and/or coding certification, such as CPC, is highly desired.
• Willingness to complete CCDS and/or coding certification after employment.

Responsibilities

• Conduct concurrent and retrospective reviews of inpatient medical records.
• Assess and help procure accurate and complete documentation of patients’ diagnoses and procedures.
• Support documentation that reflects patients’ conditions, treatments, interventions, quality of care, severity of illness, mortality risk, and risk adjustment factors.
• Support correct coding, reimbursement, and quality initiatives.
• Work with leadership, subject matter experts, and operational stakeholders to support compliance with state and federal regulatory codes and guidelines.
• Provide ongoing documentation education to physicians and clinical staff.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree