RN Clinical Document Improvement Specialist
About The Position
The Clinical Documentation Improvement (CDI) Specialist-RN is a registered nurse responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure complete, accurate, and compliant clinical documentation. This role focuses on supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity. This role works closely with providers, coders, and quality teams to clarify documentation and support accurate data capture for clinical, financial, and regulatory reporting. This role applies clinical knowledge and critical thinking skills to identify documentation gaps and facilitate timely, compliant provider clarification.
Requirements
- Associate’s Degree in Nursing (ASN) or Nursing Diploma
- Valid NYS RN licensure or eligible
Nice To Haves
- Bachelor’s Degree in Nursing (BSN)
- Working knowledge of encoding system and Excel
- Previous Coding experience
- CCS (Certified Coding Specialist) – AHIMA
- CIC (Certified Inpatient Coder)-AAPC
- CCDS (Certified Clinical Documentation Specialist)–ACDIS
Responsibilities
- Performing concurrent and retrospective reviews of inpatient medical records
- Ensuring complete, accurate, and compliant clinical documentation
- Supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity
- Working closely with providers, coders, and quality teams to clarify documentation
- Supporting accurate data capture for clinical, financial, and regulatory reporting
- Applying clinical knowledge and critical thinking skills to identify documentation gaps
- Facilitating timely, compliant provider clarification
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What This Job Offers
Job Type
Part-time
Career Level
Mid Level
Education Level
Associate degree
