CDI Nurse Specialist: Elevate Medical Record Quality

Datavant; Sacramento (CA); On-site; USD 45,000 - 50,000; Full time

Job summary

Datavant is seeking a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate medical record documentation and support accurate DRG-based coding. You will review inpatient records, work with physicians, and improve documentation clarity to ensure appropriate reimbursement and patient care outcomes.

The role requires 3+ years in CDI and clinical work in an academic medical center, RN license, and CCDS/CDIP certification, with at least 15 hours weekly availability.

Qualifications

• 3+ years of CDI experience.
• 3+ years of clinical experience in an academic medical center.
• RN license, Bachelor's degree in Nursing.
• CCDS or CDIP certification required.
• Must pass a CDI skills competency assessment.
• Must be able to accommodate a min of 15 hours per week.

Responsibilities

• Conduct timely, accurate, and complete documentation reviews for selected inpatient records, addressing inadequate or conflicting documentation.
• Collaborate with physicians and caregivers to ensure appropriate reimbursement and clinical severity for DRG-based payer patients.
• Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, secondary diagnoses, and procedure impact on DRG.
• Improve coding specificity by educating physicians and caregivers on the importance of clear documentation throughout a patient's stay.
• Follow AHA guidelines and coding clinics for accurate coding and required documentation to ensure compliance.
• Query physicians regarding missing, unclear, or conflicting health record documentation to obtain necessary details.
• Maintain daily production logs for evaluation, tracking cases reviewed, queries placed/responded, etc.
• Perform follow-up reviews to confirm recorded points of clarification in the patient's medical record.
• Ensure confidentiality of all files, documents, and records.
• Meet or exceed production and quality metrics.

Skills

CDI experience

Clinical experience

RN license

CDDS/CDIP certification

CDI skills assessment

15 hours per week availability

Education

Bachelor's degree in Nursing

Job description

Datavant is seeking a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate medical record documentation and support accurate DRG-based coding. You will review inpatient records, work with physicians, and improve documentation clarity to ensure appropriate reimbursement and patient care outcomes.

The role requires 3+ years in CDI and clinical work in an academic medical center, RN license, and CCDS/CDIP certification, with at least 15 hours weekly availability.