Clinical Documentation Improvement (CDI) Nurse

GeBBS Healthcare Solutions; Culver City (CA); Remote; USD 80,000 - 110,000; Full time

Job summary

A leading company in healthcare is seeking a Clinical Documentation Improvement (CDI) Nurse to join their remote team. The position focuses on enhancing clinical documentation quality and compliance to support optimal coding and patient care. Ideal candidates will have strong analytical skills and relevant nursing qualifications to ensure accurate medical records and compliance with coding standards.

Qualifications

• 2 years of experience in Clinical Documentation Improvement or medical record review.
• Knowledge of ICD-10, MS-DRG, APR-DRG coding systems.
• Experience in quality reporting programs.

Responsibilities

• Conduct comprehensive clinical documentation reviews for inpatient encounters.
• Identify documentation gaps to enhance accuracy and completeness.
• Collaborate with providers to ensure alignment between documentation and coding.

Skills

Analytical skills

Clinical judgment

Communication

Education

Active RN license

CDI-related certification

Tools

EHR systems

CDI software

Job description

Clinical Documentation Improvement (CDI) Nurse

Join to apply for the Clinical Documentation Improvement (CDI) Nurse role at GeBBS Healthcare Solutions

Clinical Documentation Improvement (CDI) Nurse

Join to apply for the Clinical Documentation Improvement (CDI) Nurse role at GeBBS Healthcare Solutions

Description

Employment Type: Full-Time

Schedule: Monday through Friday, Day Shift

Work Location: Remote (U.S. based)

Position Summary

We are seeking a dedicated and detail-oriented Clinical Documentation Nurse (CDI Nurse) to join our remote team. This position plays a critical role in improving the quality and completeness of clinical documentation to support accurate coding, quality measures, and regulatory compliance. This role is responsible for conducting comprehensive clinical documentation reviews that impact severity of illness (SOI), risk of mortality (ROM), Hospital-Acquired Conditions (HACs), and Patient Safety Indicators (PSIs). The goal is to ensure the medical record accurately reflects the patient's clinical status and supports the highest level of specificity for coding, quality reporting, and regulatory compliance. The ideal candidate will possess strong clinical judgment, analytical skills, and a passion for improving patient care documentation.

Requirements

Key Responsibilities

• Perform comprehensive clinical documentation reviews for all inpatient encounters, focusing on SOI, ROM, HACs, PSIs, and risk adjustment factors.
• Identify documentation gaps and opportunities to improve the accuracy and completeness of the medical record.
• Initiate compliant queries to providers for clarification or additional specificity to support appropriate diagnosis capture and DRG assignment.
• Collaborate with providers, coding professionals, and case management to support alignment between clinical documentation and coding.
• Monitor trends in documentation quality, query opportunities, and provider response rates.
• Ensure documentation supports metrics used in quality reporting, reimbursement, and publicly reported outcomes.
• Ensure documentation aligns with ICD-10-CM/PCS, MS-DRG, APR-DRG, and other relevant coding and reimbursement guidelines.
• Maintain expertise in CMS guidelines, AHRQ PSIs, coding rules, and regulatory changes.
  
  

Qualifications

• Active RN license in [State]
• CDI-related certification (e.g., CCDS, CDIP, or equivalent
• 2 years of experience in Clinical Documentation Improvement or medical record review
• Familiarity with electronic health record (EHR) systems and CDI software
• Knowledge of coding systems (ICD-10, MS-DRG, APR-DRG) and CMS guidelines
• Strong knowledge of medical terminology, anatomy, pathophysiology, and pharmacology
• Familiarity with HAC and PSI definitions, risk-adjusted outcome measures, and quality reporting programs.
• Strong analytical, critical thinking, and clinical judgment skills.
• Excellent verbal and written communication skills with experience querying providers.
• Proficiency with EHR systems and CDI software.

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

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