CDI Nurse Specialist — Elevate Medical Record Quality

Datavant; Trenton (NJ); On-site; USD 55,000 - 62,000; Full time

Job summary

Datavant is seeking a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate medical record documentation quality. You will evaluate inpatient records, engage with physicians, and drive accurate DRG-based reimbursements while ensuring compliance and patient safety.

This role requires 3+ years CDI, RN license, CCDS/CDIP, and ability to query clinicians, with production metrics and confidentiality at the core.

Qualifications

• 3+ years of CDI experience.
• 3+ years of clinical experience in an academic medical center.
• CCDS or CDIP certification required.
• Must pass a CDI skills competency assessment.

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.

Education

Registered Nurse license

Bachelor's degree in Nursing

Job description

Datavant is seeking a Clinical Documentation Quality Improvement (CDQI) Specialist to elevate medical record documentation quality. You will evaluate inpatient records, engage with physicians, and drive accurate DRG-based reimbursements while ensuring compliance and patient safety.

This role requires 3+ years CDI, RN license, CCDS/CDIP, and ability to query clinicians, with production metrics and confidentiality at the core.