CDI Nurse Specialist: Elevate Documentation & Reimbursement

Memorial Health; Springfield (IL); On-site; USD 49,593 - 78,523; Full time

Job summary

Memorial Health is seeking a Clinical Documentation Specialist to improve medical records documentation accuracy. The role involves concurrent and retrospective chart reviews, DRG assignments, and physician queries to support appropriate reimbursement.

The ideal candidate has 3–5 years of acute care or home health nursing experience, an Illinois RN license, BSN preferred, and CCDS preferred. Strong communication and collaboration with HIM Coding are essential.

Qualifications

• BSN preferred.
• Current RN licensure in the State of Illinois required.
• Certified Clinical Documentation Specialist (CCDS) preferred.
• Minimum of 3-5 years of recent acute care or home health nursing experience required.
• Experience in assigning DRGs based on clinical documentation to facilitate reimbursement.

Responsibilities

• Completes thorough chart review for identified inpatient accounts, assigns working DRG and alternative DRG if appropriate at admission.
• Reviews clinical documentation to improve accuracy of severity of illness, risk of mortality, and care complexity.
• Documents CC/MCCs appropriately to reflect potential diagnoses.
• Initiates physician queries to resolve missing or conflicting information.
• Conducts follow-up reviews to ensure clarifications are recorded in the chart.
• Consults physician advisor when indicated by reviews or query responses.
• Partners with HIM Coding staff to ensure data accuracy and documentation completeness.
• Uses HIM Coding feedback for self-improvement and discusses concerns with manager.
• Provides support as a clinical resource to HIM Coding Team.
• Participates in education regarding regulatory and payor requirements for documentation and reimbursement optimization.
• Implements staff and physician education on documentation initiatives.
• Implements quality improvement activities related to clinical documentation.
• Serves as a resource for managers, staff, and physicians on reporting standards and regulatory requirements.
• Adheres to Memorial Behavioral Standards.
• Participates in weekend coverage schedule.
• Assists with departmental data collection and analysis as needed.
• Performs other duties as assigned.

Skills

Communication skills

Clinical documentation knowledge

Query process understanding

Education

RN licensure in Illinois

BSN

CCDS certification preferred

Job description

Memorial Health is seeking a Clinical Documentation Specialist to improve medical records documentation accuracy. The role involves concurrent and retrospective chart reviews, DRG assignments, and physician queries to support appropriate reimbursement.

The ideal candidate has 3–5 years of acute care or home health nursing experience, an Illinois RN license, BSN preferred, and CCDS preferred. Strong communication and collaboration with HIM Coding are essential.