Clinical Documentation Specialist – CDI & Coding Quality

Rhode Island Hospital; Providence (RI); On-site; USD 87,000 - 174,000; Full time

Job summary

Brown University Health in Providence, RI seeks a Clinical Documentation Specialist to perform concurrent auditing of medical records to ensure documentation accurately reflects severity of illness, risk of mortality, and complexity of care.

The role collaborates with physicians, mid-level providers, nursing staff, and coding staff to improve documentation quality and support accurate MS-DRG assignment. The successful candidate will maintain CDI databases and support timely documentation.

Qualifications

• RN licensed in Rhode Island with 3 years of clinical experience.
• BSN required; master's degree preferred.
• PA/NP licensure or MD with 2 years clinical documentation experience.

Responsibilities

• Perform concurrent auditing of the medical record to ensure documentation reflects severity of illness, risk of mortality and care.
• Identify documentation gaps and opportunities to clarify incomplete or conflicting notes.
• Develop concise queries and discuss patient care with physicians/mid-level providers.
• Enter diagnoses and procedures accurately to assist with MS-DRG/DRG assignment.
• Maintain the CDI database and perform DRG reconciliation to ensure accurate coding.

Skills

Clinical documentation

Documentation queries

MS-DRG assignment

Education

Rhode Island RN license

BSN degree

MSN preferred

PA/NP licensure or MD with CDS experience

Tools

3M encoder

Job description

Brown University Health in Providence, RI seeks a Clinical Documentation Specialist to perform concurrent auditing of medical records to ensure documentation accurately reflects severity of illness, risk of mortality, and complexity of care.

The role collaborates with physicians, mid-level providers, nursing staff, and coding staff to improve documentation quality and support accurate MS-DRG assignment. The successful candidate will maintain CDI databases and support timely documentation.