RN Clinical Documentation Improvement Specialist

Job Summary

As a full-time RN Clinical Documentation Improvement Specialist working remotely, the candidate will utilize clinical and coding knowledge to conduct concurrent and retrospective reviews of inpatient medical records, focusing on enhancing documentation quality and supporting accurate coding and compliance.

Key responsibilities

• Conduct clinically based reviews of medical records to identify documentation improvement opportunities
• Engage with physicians to clarify ambiguous documentation through queries and rounding
• Educate healthcare staff on documentation requirements and coding guidelines to ensure compliance and accuracy

Required qualifications

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