Inpatient CDI Specialist

University Health; San Antonio (TX); On-site; USD 85,000 - 100,000; Full time

Job summary

University Health is seeking a clinically competent Registered Nurse for clinical documentation improvement within its inpatient units. You will collaborate with the healthcare team to ensure accurate documentation and appropriate coding reflects the patient’s care and outcomes.

The role requires engagement with ACDIS/AHIMA guidelines, ROM and SOI considerations, and ongoing knowledge of Epic workflows and 3M principles to maximize reimbursement and care quality.

Qualifications

• Bachelor's degree in nursing required or preferred.
• Three years recent, full-time hospital experience preferred.
• Clinical Documentation Improvement course within specified time of hire.

Responsibilities

• Care for the assigned inpatient population with clinical competence.
• Review patient accounts for accurate documentation and query providers as needed.
• Query per ACDIS/AHIMA guidelines to ensure complete documentation during the stay.
• Promote documentation reflecting ROM and SOI for maximum reimbursement.
• Maintain knowledge of coding guidelines, ACDIS standards, Epic workflows and 3M principles.

Education

Bachelor's degree in nursing

Tools

Epic workflows

3M principles

Job description

University Health is seeking a clinically competent Registered Nurse for clinical documentation improvement within its inpatient units. You will collaborate with the healthcare team to ensure accurate documentation and appropriate coding reflects the patient’s care and outcomes.

The role requires engagement with ACDIS/AHIMA guidelines, ROM and SOI considerations, and ongoing knowledge of Epic workflows and 3M principles to maximize reimbursement and care quality.