CDI Specialist: Elevate Patient Records & Care Quality

San Juan Regional Medical Center; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

San Juan Regional Medical Center is seeking a Clinical Documentation Improvement (CDI) Specialist with a strong nursing background to review inpatient records for accuracy and coding alignment. The role collaborates with physicians, case management, and coding to close documentation gaps and improve DRG assignment.

The ideal candidate holds an active New Mexico RN license, has at least three years of acute care experience, and demonstrates excellent communication and analytical skills.

Qualifications

• Registered nurse with at least 3 years of acute care experience.
• Current New Mexico RN licensure.
• Excellent written and verbal communication skills.
• Strong analytical thinking and attention to detail.
• Team-oriented with solid organizational skills.
• Basic computer skills and ability to use documentation systems.

Responsibilities

• Comprehensively reviews patient records to assure accurate severity of illness representation.
• Assigns Working DRG and reviews documentation with physicians, case management, and coding.
• Identifies gaps in physician documentation and drives improvement interventions.
• Identifies CDI best practices and benchmarks to support compliance objectives.
• Stays current on coding, compliance, guidelines, and payer requirements related to MS-DRG.

Skills

CDI

Nursing

Analytical thinking

Team-oriented

Communication skills

Basic computer skills

Education

RN License (NM)

Job description

San Juan Regional Medical Center is seeking a Clinical Documentation Improvement (CDI) Specialist with a strong nursing background to review inpatient records for accuracy and coding alignment. The role collaborates with physicians, case management, and coding to close documentation gaps and improve DRG assignment.

The ideal candidate holds an active New Mexico RN license, has at least three years of acute care experience, and demonstrates excellent communication and analytical skills.