CDI Specialist: Clinical Documentation Excellence (Remote)

Trinity Health; Minot (ND); On-site; USD 65,000 - 90,000; Full time

Job summary

Trinity Health in the United States is seeking a CDI Specialist to improve the accuracy, clarity, and completeness of clinical documentation across inpatient, same-day surgery, observation, and emergency encounters.

You will perform concurrent medical record reviews, identify opportunities to strengthen documentation, and collaborate with physicians, nursing staff, CEPS and HIM coding teams to ensure severity of illness and risk of mortality are accurately reflected.

Qualifications

• Associate or Bachelor’s Degree in Nursing required.
• RHIT or RHIA or other Clinical Healthcare field required.
• Current or temporary RN license in ND or compact RN licensure required; OR LPN designation; CCDS or CDIP certification may be required.

Responsibilities

• Perform concurrent clinical documentation reviews to evaluate accuracy, completeness, and clinical relevance of diagnoses, procedures, and supporting indicators.
• Collaborate with providers, nursing staff, CEPS, and HIM coding teams to clarify documentation and ensure severity of illness and risk of mortality are appropriately reflected.
• Initiate and track documentation queries in accordance with organizational guidelines and regulatory expectations.
• Analyze working DRGs/APCs and recommend documentation updates needed for accurate coding, reimbursement, and quality reporting.
• Educate providers and clinical staff on documentation best practices, regulatory requirements, and opportunities for improvement.
• Maintain organized documentation, reporting, and communication workflows to support CDI program goals and performance monitoring.

Skills

Critical thinking

Problem solving

Organizational skills

Deductive reasoning

Communication skills

Interpersonal skills

Willingness to learn

Education

Associate or Bachelor’s Degree in Nursing

RHIT or RHIA or other Clinical Healthcare field

Tools

EMR systems

Job description

Trinity Health in the United States is seeking a CDI Specialist to improve the accuracy, clarity, and completeness of clinical documentation across inpatient, same-day surgery, observation, and emergency encounters.

You will perform concurrent medical record reviews, identify opportunities to strengthen documentation, and collaborate with physicians, nursing staff, CEPS and HIM coding teams to ensure severity of illness and risk of mortality are accurately reflected.