Clinical Documentation Expert | Nursing CDI

Northwell Health; Village of Lake Success (NY); On-site; USD 85,000 - 100,000; Full time

Job summary

Northwell Health in New York is seeking a Registered Nurse with a BSN to support clinical documentation improvement (CDI). You will perform concurrent inpatient record reviews, generate queries, and work with physicians to clarify documentation for accurate coding and reimbursement.

Requirements include a BSN, an active RN license, NYS registration within three months, and 1–3 years of relevant CDI experience. Strong communication and attention to detail are essential.

Qualifications

• Accredited nursing program; BSN required or must obtain within 5 years.
• Active RN license in any US state; NYS license required within three months of employment.
• 1–3 years of relevant CDI/inpatient documentation experience.

Responsibilities

• Facilitates clarification of clinical documentation ensuring accuracy and integrity in the medical record.
• Produces queries and follows up with physicians for documentation clarification.
• Performs concurrent inpatient record reviews to support accurate coding and reimbursement.
• Interacts with physicians to discuss documentation requirements and provide timely responses to queries.
• Educates medical staff on clinical documentation opportunities that impact accuracy of the medical record.
• Records outcome data in CDI software and tracks audit results and revenue impact.

Skills

Clinical documentation

Physician communication

Attention to detail

Education

BSN

Tools

ICD-10-CM

ICD-10-PCS

MS-DRG

APR NY

APR National

Job description

Northwell Health in New York is seeking a Registered Nurse with a BSN to support clinical documentation improvement (CDI). You will perform concurrent inpatient record reviews, generate queries, and work with physicians to clarify documentation for accurate coding and reimbursement.

Requirements include a BSN, an active RN license, NYS registration within three months, and 1–3 years of relevant CDI experience. Strong communication and attention to detail are essential.