RN Nurse Clinical Documentation Improvement Specialist
About The Position
As a Clinical Documentation Improvement (CDI) Specialist at R1, you will use clinical and coding knowledge to conduct clinically based concurrent and retrospective reviews of inpatient medical records. You will evaluate clinical documentation for opportunities to improve its quality, including focused reviews of mortality, PSI, and other areas identified by CDI leadership. You will facilitate appropriate physician documentation of clinical conditions and procedures to support accurate representation of severity of illness, expected risk of mortality, and complexity of care. The role also involves participating in ongoing documentation improvement initiatives and providing formal and informal education to providers and the CDI team. R1 combines revenue cycle expertise with technology such as analytics, AI, intelligent automation, and workflow orchestration to support hospitals, health systems, and medical groups. Its culture emphasizes collaboration, adaptability, and improving healthcare experiences for patients and providers.
Requirements
- Associate’s degree in nursing; a bachelor’s degree in nursing is preferred.
- Active US RN license.
- Front-line CDI experience in an acute care hospital.
- Three to five years of recent clinical work experience in medical-surgical nursing, ICU, telemetry, and/or emergency department.
- Knowledge or experience with electronic medical record (EMR) platforms and CDI platforms.
- Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes and evaluation of medical record data for accuracy and reimbursement.
- Self-motivated to stay abreast of CMS rules and regulations and incorporate changes into daily practice.
Nice To Haves
- Bachelor’s degree in nursing.
Responsibilities
- Review inpatient medical records concurrently and retrospectively to identify opportunities to improve clinical documentation.
- Conduct focused reviews identified by CDI leadership, including mortality reviews, PSI reviews, and other projects.
- Initiate physician interaction through the query process or participation in physician rounding when medical record information is ambiguous, missing, or conflicting; request documentation needed for accurate coding and compliance, including accurate reflection of CMI, LOS, and resource utilization.
- Educate physicians and other staff on documentation requirements, coding guidelines, and reimbursement policies.
- Use hospital coding code sets, policies and procedures, federal and state coding and reimbursement guidelines, and Coding Clinic Guidelines to assign a working DRG and review records for the highest specificity of coding.
- Collaborate with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues and improve coding accuracy.
- Stay current on developments and changes in clinical documentation standards, coding rules, and regulatory requirements.
- Participate in ongoing documentation improvement initiatives and provide formal and informal education to providers and the CDI team.
Benefits
- Competitive benefits package.
- Eligible to participate in the annual bonus plan at a target of 5.00%.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
