CDI Nurse Specialist: Elevate Clinical Documentation

MedStar Health; Columbia (MD); On-site; USD 85,000 - 120,000; Full time

Job summary

MedStar Health is seeking a Clinical Documentation Integrity Specialist to ensure accurate documentation reflecting patient risk of mortality and severity of illness. The role collaborates with coding teams to assign correct ICD-10 and DRG, develops physician queries, and educates clinical staff.

The position requires nursing experience in acute care, CDI/CDI-related certifications within two years, and strong data analysis skills.

Qualifications

• Associate's degree in Nursing is required or higher degrees preferred.
• 3-4 years of nursing experience in acute care is required.
• Experience in ICD-10 coding review and DRG reimbursements systems required.
• CDIP or CCDS certifications within 2 years required; CCS-Certified Coding Specialist preferred.

Responsibilities

• Contributes to the achievement of department goals and adheres to policies and quality standards.
• Collaborates with CDI team, nursing staff, medical staff, and ancillary departments.
• Uses CDI resources to ensure precise clinical details and data entry for MS-DRG/APR-DRG assignments.
• Develops physician queries in line with AHIMA/ACDIS guidelines and regulatory requirements.
• Identifies education opportunities and provides ongoing education to clinicians about accurate documentation.
• Records daily review data including cases reviewed, queries, and DRG determinations.
• Maintains continuing education and credentials for the CDI role.
• Participates in meetings, committees, and hospital outreach as required.
• Analyzes CDI data to identify improvement opportunities and educates staff.

Skills

Excellent interpersonal skills

Verbal and written communication

Critical-thinking

Data analysis

Education

Associate's degree in Nursing

Bachelor's degree in Nursing

Master's degree in Nursing or related field

Doctoral degree Foreign Medical Graduate preferred

Tools

Microsoft Office

Job description

MedStar Health is seeking a Clinical Documentation Integrity Specialist to ensure accurate documentation reflecting patient risk of mortality and severity of illness. The role collaborates with coding teams to assign correct ICD-10 and DRG, develops physician queries, and educates clinical staff.

The position requires nursing experience in acute care, CDI/CDI-related certifications within two years, and strong data analysis skills.