CDI Specialist: Elevate Clinical Documentation Quality

Capital Health (US); Trenton (NJ); On-site; USD 53,726 - 70,257; Full time

Benefits offered by this job

Medical Plan

Dental Plan

Vision Plan

FSA

Retirement Savings

Job summary

Capital Health in New Jersey is seeking a Clinical Documentation Specialist to improve documentation quality and accuracy for DRG assignment. You will collaborate with physicians, nurses, and coding staff to ensure comprehensive records and compliance with CDI guidelines.

Ideal candidates will have RN licensure, CDI credentials, and experience in acute care settings, with strong communication and EMR proficiency.

Qualifications

• RN license required.
• CCDS/CDIP credential preferred.
• Two years’ acute care or three years coding/CDI hospital experience preferred.

Responsibilities

• Review and improve patient record documentation for accurate DRG, severity, and risk.
• Query physicians for missing or unclear documentation.
• Educate care teams on documentation guidelines and CDI principles.
• Collaborate with coding staff to ensure data accuracy and DRG assignment.

Skills

RN license

CDIS/CDIP knowledge

Clinical documentation

Verbal and written communication

EMR navigation

Education

RN degree

BSN preferred

Tools

EMR systems

Encoding software

Job description

Capital Health in New Jersey is seeking a Clinical Documentation Specialist to improve documentation quality and accuracy for DRG assignment. You will collaborate with physicians, nurses, and coding staff to ensure comprehensive records and compliance with CDI guidelines.

Ideal candidates will have RN licensure, CDI credentials, and experience in acute care settings, with strong communication and EMR proficiency.