Inpatient RN CDI Specialist: Drive Accurate Documentation

RCM Holdco; United States; Presencial; USD 52.000 - 98.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Annual bonus plan (target 5%)

Descripción de la vacante

R1 is seeking a Clinical Documentation Improvement (CDI) Specialist in the United States. You will perform concurrent and retrospective reviews of inpatient records, identify opportunities to improve documentation quality and support appropriate severity of illness and resource use.

You will engage physicians, educate teams on documentation rules, and ensure coding accuracy across DRG assignments, while staying current with CMS guidelines and regulatory changes.

Formación

• Associate's Degree in Nursing (Bachelor's preferred) and active US RN license.
• 3–5 years of recent clinical work in med-surg, ICU, telemetry or ED.
• Front line CDI experience in an acute care hospital; EMR and CDI platform familiarity.

Responsabilidades

• Initiates physician interaction when documentation is ambiguous or missing, via physician queries and rounding.
• Educates physicians and staff on documentation requirements, coding guidelines and reimbursement policies.
• Uses coding guidelines and hospital policies to assign working DRG and ensure codes reflect highest specificity.
• Collaborates with coders, auditors and quality teams to resolve documentation issues.
• Keeps updated on changes in clinical documentation standards and regulatory requirements.

Conocimientos

CDI knowledge

Front line CDI experience

Medical record review

Communication skills

Educación

Associate's Degree in Nursing

Bachelor's Degree in Nursing preferred

Herramientas

EMR platforms

CDI platforms

Descripción del empleo

R1 is seeking a Clinical Documentation Improvement (CDI) Specialist in the United States. You will perform concurrent and retrospective reviews of inpatient records, identify opportunities to improve documentation quality and support appropriate severity of illness and resource use.

You will engage physicians, educate teams on documentation rules, and ensure coding accuracy across DRG assignments, while staying current with CMS guidelines and regulatory changes.