CDI Specialist: Elevate Clinical Documentation

Trinity Health; Minot (ND); On-site; USD 75,816 - 117,520; Full time

Job summary

Trinity Health in Minot, ND seeks a CDI Specialist to improve accuracy and completeness of clinical documentation across inpatient, same-day surgery, observation, and ER encounters. You will conduct concurrent medical record reviews and work with physicians and HIM teams.

The role emphasizes documenting true clinical acuity, compliant coding, and data reliability for reporting and outcomes. Requires nursing licensure and CDI certifications; 3+ years acute care experience or 5+ years coding in

Qualifications

• 3+ years clinical experience in acute care or outpatient (Same Day Surgery, ER, or Observation).
• Or 5+ years acute care, same day surgery, ER or observation coding experience.
• Current ND or compact RN license, or LPN, or CCDS/CDIP certification.
• Associate or Bachelor’s Degree in Nursing or RHIT/RHIA required.

Responsibilities

• Perform concurrent reviews of diagnoses and procedures for accuracy and completeness.
• Collaborate with providers and HIM teams to clarify documentation and reflect severity.
• Initiate and track documentation queries per guidelines and regulatory expectations.
• Analyze DRGs/APCs and recommend documentation updates for accurate coding.
• Educate staff on documentation practices and regulatory requirements.
• Maintain organized documentation workflows to support CDI program goals.

Skills

Critical thinking

Problem solving

Organizational skills

Deductive reasoning

Clinical knowledge

Interpersonal skills

Communication skills

HIPAA compliance

Education

Associate or Bachelor’s Degree in Nursing

RHIT or RHIA (Health Information Management)

Nursing or healthcare degree related field

Tools

Electronic Medical Records

Job description

Trinity Health in Minot, ND seeks a CDI Specialist to improve accuracy and completeness of clinical documentation across inpatient, same-day surgery, observation, and ER encounters. You will conduct concurrent medical record reviews and work with physicians and HIM teams.

The role emphasizes documenting true clinical acuity, compliant coding, and data reliability for reporting and outcomes. Requires nursing licensure and CDI certifications; 3+ years acute care experience or 5+ years coding in