CDI Specialist: Elevate Documentation & Reimbursement

R1 RCM; United States; On-site; USD 48,000 - 81,000; Full time

Benefits offered by this job

Annual bonus plan (target 5%)

Competitive benefits package

Career growth opportunities

Job summary

R1 RCM is seeking a Clinical Documentation Improvement (CDI) Specialist to review inpatient records and improve documentation quality. You will work to optimize severity of illness and resource utilization through physician queries and education.

The role requires a nursing degree with RN license and 3–5 years in clinical settings, plus CDI and EMR platform familiarity; strong independent work and collaboration abilities are essential.

Qualifications

• Associate degree in nursing; RN license required.
• 3–5 years of clinical work in medical-surgical, ICU, telemetry, or ED.
• CMS rules and CDI knowledge and practical application in documentation.

Responsibilities

• Initiate physician interaction for clarification to support accurate coding and CMI reflection.
• Educate physicians and staff on documentation, coding guidelines, and reimbursement policies.
• Use coding guidelines to assign working DRG and ensure high specificity.
• Collaborate with coders, auditors, and quality teams to resolve documentation issues.
• Stay updated on clinical documentation standards, coding rules, and regulatory requirements.
• Conduct focused reviews in Mortality/PSI areas and other CDI projects.
• Assist with onboarding and training of new CDI team members.

Skills

CDI practices

Coding knowledge

Documentation requirements

CMS rules & regulations

Interpersonal skills

Self-directed/initiative

Independent problem solving

MS Office suite

CDI platforms learnability

Team collaboration

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing preferred

Tools

EMR platforms

MS Teams

MS SharePoint

OneDrive

CDE One

Job description

R1 RCM is seeking a Clinical Documentation Improvement (CDI) Specialist to review inpatient records and improve documentation quality. You will work to optimize severity of illness and resource utilization through physician queries and education.

The role requires a nursing degree with RN license and 3–5 years in clinical settings, plus CDI and EMR platform familiarity; strong independent work and collaboration abilities are essential.