Registered Nurse - CDI

Aptive•Memphis, TN

9d•Onsite

About The Position

The Registered Nurse CDI Specialist will serve as the Clinical Documentation Integrity Registered Nurse Advisor (CDI RNA) , providing advanced nursing and clinical expertise to enhance documentation quality for inpatient and outpatient services. This role supports clinical documentation improvement (CDI) strategies, ensuring accurate, ethical, and compliant health record documentation in alignment with VA, CMS, and Joint Commission standards.

Requirements

Active, unrestricted license as a Registered Nurse (RN)
Minimum 2 years of CDI experience in a hospital setting.
CDI certification from AHIMA, ACDIS, or AAPC
Strong knowledge of CMS guidelines, VHA Directives, The Joint Commission standards, ICD-10-CM, and SNOMED-CT.
Excellent communication, analytical thinking, and education facilitation skills.

Nice To Haves

Experience with clinical documentation in trauma, teaching, federal, or tertiary care hospitals preferred.

Responsibilities

Act as the CDI Nursing Advisor and clinical subject matter expert for documentation issues.
Apply nursing process to review clinical data for validation, quality trends, and documentation opportunities.
Collaborate with providers, CDIS, and HIM staff to improve documentation accuracy through verbal, written, or electronic queries.
Develop SOPs, workflows, turnaround times, and training materials to improve documentation integrity.
Assist in the design and execution of educational seminars, workshops, and provider training on documentation practices.
Guide providers in using SNOMED-CT and updating problem lists aligned with ICD-10-CM standards.
Conduct concurrent and retrospective chart reviews to clarify clinical documentation, including ambiguous admission orders.
Contribute to provider education on clinical indicators and support facility newsletter articles or educational content.
Assist in quality reviews including mortality, CMS measures, and code reconciliation activities.
Engage in CDI-related escalations, reconciliations, and ensure collaboration between coders and CDI team.