Clinical Documentation Specialist (RN) – CDI & Coding

Sinai-Grace Hospital; Anniston (AL); On-site; USD 65,000 - 80,000; Full time

Job summary

Conifer Health is seeking a CDI Specialist to review patient records and improve physician documentation to support accurate MS-DRG assignment and severity of illness. You will educate care teams on documentation guidelines and coding requirements, ensuring timely reviews and productive physician queries.

The role requires nursing or medical degree, CDI experience, and knowledge of MS-DRG classification. Travel up to 10% may be required; join a team focused on quality, compliance, and patient

Qualifications

• CDI Specialist must understand documentation guidelines and MS-DRG rules.
• Ability to educate care teams on documentation guidelines and coding practices.
• Capable of formulating clinically compliant physician queries.

Responsibilities

• Review medical records within 24-48 hours of admission to assess documentation for MS-DRG accuracy.
• Perform follow-up reviews every 24-48 hours through discharge.
• Formulate physician queries to obtain missing or unclear documentation.
• Collaborate with providers and care teams to resolve queries before discharge.
• Stay current with coding guidelines and participate in CDI training sessions.
• Assist in training staff new to CDI and support program monitoring.

Skills

CDI Knowledge

Teamwork

Time management

Communication

Problem solving

Education

BSN or higher nursing degree

MD or Foreign MD

Tools

MS Word/Excel

Job description

Conifer Health is seeking a CDI Specialist to review patient records and improve physician documentation to support accurate MS-DRG assignment and severity of illness. You will educate care teams on documentation guidelines and coding requirements, ensuring timely reviews and productive physician queries.

The role requires nursing or medical degree, CDI experience, and knowledge of MS-DRG classification. Travel up to 10% may be required; join a team focused on quality, compliance, and patient