CDI & Clinical Documentation Specialist

Best Care; Omaha (NE); On-site; USD 75,000 - 105,000; Full time

Job summary

Nebraska Methodist Health System in Omaha is seeking a registered nurse to perform concurrent review of clinical documentation for admitted patients, ensuring accurate diagnoses and procedures are captured. You will work Mon-Fri, daytime hours at Methodist Hospital, collaborating with physicians, coders, and care teams to improve documentation quality and support quality reporting.

A BSN is preferred; an active RN license is required; five years of clinical experience in medical-surgical, ICU,

Qualifications

• Graduate of an accredited school of nursing.
• RN license current and active; multi-state/compact license acceptable.
• Five years of clinical experience in medical-surgical nursing and/or ICU, case management, or inpatient coding.
• BSN preferred; mandatory annual education requirements completed.

Responsibilities

• Performs concurrent review of clinical documentation to ensure accurate diagnoses and procedures.
• Assists with physician queries to capture severity of illness and correct ICD-10 codes.
• Initiates professional communication with physicians when documentation is unclear or incomplete.
• Tracks responses to documentation questions to identify opportunities for education.
• Collaborates with coding staff to clarify documentation issues on a regular basis.
• Provides education/training to physicians, nurses, and coders across settings.

Skills

Excellent communication

Collaboration with physicians

Teaching/education

Critical thinking

Healthcare workflow knowledge

Education

BSN preferred

Job description

Nebraska Methodist Health System in Omaha is seeking a registered nurse to perform concurrent review of clinical documentation for admitted patients, ensuring accurate diagnoses and procedures are captured. You will work Mon-Fri, daytime hours at Methodist Hospital, collaborating with physicians, coders, and care teams to improve documentation quality and support quality reporting.

A BSN is preferred; an active RN license is required; five years of clinical experience in medical-surgical, ICU,