CDI Specialist: Elevate Inpatient Documentation

mercy; Missouri; On-site; USD 65,000 - 90,000; Full time

Job summary

Mercy is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation for SOI, ROM, and treatment intensity. You will collaborate with care teams to reflect the true clinical scenario and improve documentation quality.

Qualified candidates hold RN/BSN and coding credentials (CCS, RHIA/RHIT or related) with 1 year of acute care HIM experience.

Qualifications

• RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP credentials are acceptable.
• Minimum 1 year of related acute care inpatient nursing, inpatient coding, or HIM experience.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient medical records.
• Identify opportunities to ensure accurate and complete clinical documentation.
• Collaborate with inpatient care teams to reflect true clinical scenarios and SOI/ROM.
• Maintain confidentiality and adhere to Mercy standards and policies.
• Support documentation quality improvement initiatives and education.

Skills

Critical thinking

Communication

Workflow management

Typing

Excel

Word

Data entry

Clinical data interpretation

Team collaboration

Independence

Education

RN

BSN

RHIA

RHIT

CCS

CPC

CIC

CDDS

Tools

Excel

Word

Job description

Mercy is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring accurate documentation for SOI, ROM, and treatment intensity. You will collaborate with care teams to reflect the true clinical scenario and improve documentation quality.

Qualified candidates hold RN/BSN and coding credentials (CCS, RHIA/RHIT or related) with 1 year of acute care HIM experience.