CDI Specialist: Elevate Clinical Documentation & Compliance

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

Job summary

Trinity Health in Minot, ND is seeking a CDI Specialist to improve the accuracy and completeness of clinical documentation across inpatient and outpatient settings. You will perform concurrent reviews, identify documentation gaps, and work with physicians, nurses, CEPS and HIM to ensure true clinical acuity and appropriate coding.

The role emphasizes education, collaboration, and compliance, with responsibilities to query documentation, analyze DRGs, and support quality reporting.

Qualifications

• Active ND RN license or compact RN licensure, or LPN designation; CCDS or CDIP credentials preferred.
• Associate or Bachelor’s Degree in Nursing or RHIT/RHIA or related healthcare field.
• Minimum 3+ years in acute care or 5+ years coding/records experience in relevant settings.

Responsibilities

• Perform concurrent clinical documentation reviews for accuracy, completeness, and relevance of diagnoses and procedures.
• Collaborate with physicians, nursing staff, CEPS, and HIM to ensure accurate reflection of severity of illness and risk of mortality.
• Initiate and track documentation queries according to guidelines and regulatory expectations.
• Analyze DRGs/APCs and recommend documentation updates for correct coding and quality reporting.
• Educate providers and staff on documentation best practices and regulatory requirements.
• Maintain organized documentation, reporting, and communication workflows to support CDI program goals.

Skills

Critical thinking

Excellent communication

Problem solving

Organizational skills

Deductive reasoning

Education

Associate or Bachelor’s Degree in Nursing

RHIT or RHIA

Clinical Healthcare field

Tools

EMR literacy

HIPAA compliance

Job description

Trinity Health in Minot, ND is seeking a CDI Specialist to improve the accuracy and completeness of clinical documentation across inpatient and outpatient settings. You will perform concurrent reviews, identify documentation gaps, and work with physicians, nurses, CEPS and HIM to ensure true clinical acuity and appropriate coding.

The role emphasizes education, collaboration, and compliance, with responsibilities to query documentation, analyze DRGs, and support quality reporting.