RN Clinical Documentation Improvement Specialist

Job Summary

Working remotely on a full-time basis, the RN Clinical Documentation Improvement Specialist will utilize clinical and coding knowledge to conduct concurrent and retrospective reviews of inpatient medical records, focusing on improving documentation quality and collaborating with healthcare providers to ensure accurate coding and compliance.

Key responsibilities

• Conduct clinically based reviews of medical records to identify documentation improvement opportunities
• Engage with physicians to clarify ambiguous or missing documentation through the physician query process
• Educate healthcare staff on documentation requirements, coding guidelines, and reimbursement policies

Required qualifications

• Associate's Degree in Nursing (Bachelor's Degree preferred)
• An active US RN license is required
• Front line CDI experience in an acute care hospital
• Three to five years of recent clinical work experience in medical-surgical, ICU, telemetry, or emergency department
• Knowledge or experience with electronic medical records (EMR) and CDI platforms