Clinical Documentation Improvement Specialist - RN

Gibsongeneral; Evansville (IN); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a Clinical Documentation Improvement Specialist to enhance the quality of patient documentation. This role involves evaluating medical records, ensuring accuracy, and collaborating with various departments to improve documentation practices. The ideal candidate will have extensive clinical experience and an active RN license. The company offers a flexible work environment, professional development opportunities, and comprehensive healthcare benefits, making it an attractive place for dedicated healthcare professionals looking to make a significant impact in patient care.

Benefits

Flexible work schedules

Onsite children’s care centers

Payactiv-earned wage benefit

Qualifications

• Active RN license in Indiana and Kentucky or a compact license state.
• Minimum of five years of related adult, acute clinical experience.

Responsibilities

• Evaluate concurrent documentation to ensure medical records reflect patient conditions.
• Communicate the need for additional documentation to medical and clinical staff.

Skills

Clinical Documentation Improvement

Patient Care

Communication

Collaboration

Education

Bachelor's Degree in Nursing (BSN)

Job description

Clinical Documentation Improvement Specialist - RN

Job Category: Outpatient Nursing

Requisition Number: CLINI008522

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• Posted: May 8, 2025
• Full-Time
• Remote

Locations

Showing 1 location

HRS Lloyd Expressway
1419 W Lloyd Expy
Evansville, IN 47710, USA

Eligible for evening/night, weekend shift incentive based on company policies and applicable job codes. Additional details will be provided during the interview process.

Bonus: Potential for a performance-based bonus, subject to eligibility criteria and achievement of defined metrics. Details regarding bonus eligibility and performance goals will be provided during the interview process or upon hire.

We pride ourselves in retaining our top talent by offering work environments that support professional development and personal success. In addition to our robust healthcare and retirement plans, we offer:

• Flexible work schedules – Full time/part time/supplemental – Day/Eve/Night
• Onsite children’s care centers (Infant through Pre-K)
• Payactiv-earned wage benefit-work today, get paid tomorrow

Day-to-day, our Clinical Documentation Improvement Specialists are primarily responsible for evaluating concurrent documentation to ensure the medical record accurately reflects the severity and risk of the patient’s conditions. Under the supervision of CDI Leadership, CDI Specialists will review medical records to identify missing, vague, or incomplete diagnoses; communicate the need for additional documentation to the appropriate medical and clinical staff; ensure the additional documentation is completed in a timely manner; and work collaboratively with other departments including Coding, Quality, Compliance, Medical Staff, Utilization Review/Case Management, Medical Records, and others to improve physician documentation quality. This role supports initiatives to enhance documentation quality by all caregivers.

Required: Certifications/Licenses/Experience:

• Active Registered Nurse (RN) license in Indiana and Kentucky or a compact license state
• Minimum of five (5) years of related adult, acute clinical experience

Preferred: Certifications/Licenses/Experience:

• Bachelor's Degree in Nursing (BSN)
• ACDIS certification preferred

Department: Healthcare Resource Solutions (HRS)

Shift: Day

Hours: Full-time, 40 hours/week

Additional Information

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.