Hospital CDI Specialist for DRG Accuracy & Documentation

Sinai Chicago; Chicago (IL); On-site; USD 70,000 - 90,000; Full time

Job summary

A healthcare organization in Chicago is seeking a Clinical Documentation Integrity Specialist to oversee the accuracy of clinical documentation for inpatient medical records. This role involves conducting documentation reviews, collaborating with healthcare providers and coding teams, and ensuring compliance with coding guidelines. The ideal candidate will hold a relevant degree and appropriate certifications while having extensive clinical experience in acute care settings. This position plays a key role in supporting quality and performance improvement initiatives within the organization.

Qualifications

• 3 years of clinical experience in acute care nursing or equivalent.
• 2 years of experience in CDI, inpatient coding, or case management.
• Certification as CCDS or CDIP preferred within 12 months of hire.

Responsibilities

• Conducts concurrent clinical documentation reviews for assigned inpatient cases.
• Initiates compliant physician queries for clarification.
• Collaborates with physicians and coding teams to ensure accurate documentation.
• Participates in daily clinical rounds and case management discussions.
• Reviews documentation related to key quality metrics.

Skills

ICD-10-CM/PCS knowledge

Clinical judgment

Critical thinking skills

Ability to interpret complex clinical data

Education

Bachelor’s degree in Nursing, Health Information Management, or related healthcare field

Active RN, LPN, RHIA, or RHIT credential

Tools

3M CDI platform

Optum CDI platform

Job description

A healthcare organization in Chicago is seeking a Clinical Documentation Integrity Specialist to oversee the accuracy of clinical documentation for inpatient medical records. This role involves conducting documentation reviews, collaborating with healthcare providers and coding teams, and ensuring compliance with coding guidelines. The ideal candidate will hold a relevant degree and appropriate certifications while having extensive clinical experience in acute care settings. This position plays a key role in supporting quality and performance improvement initiatives within the organization.