IP CDI Nurse

ACDIS Pediatric Networking Group; United States; Remote; USD 80,000 - 110,000; Full time

Job summary

ACDIS Pediatric Networking Group is seeking a Senior Clinical Documentation Specialist (CDI) to review inpatient records, identify documentation gaps, and develop compliant physician queries. You will evaluate diagnoses, procedures, and DRG opportunities, support ICD-10-CM/PCS coding, and collaborate with physicians, coders, and clinical teams to drive quality metrics.

Applicants should hold a nursing license (PHRN/USRN), have 3–4+ years clinical experience (ICU preferred) or 4+ years in

Qualifications

• PHRN/USRN license and CDI credentials.
• 3+ years clinical experience; critical care or emergency preferred.
• IP CDI experience preferred; 4+ years in acute care acceptable.
• Strong ICD-10-CM/PCS, DRG, CC/MCC, SOI and ROM knowledge.
• Experience with physician queries and documentation clarification.
• Excellent written and verbal English communication.
• Epic or major EHR platform experience preferred.
• CDI certification (CDIP, CCDS, CIC) highly preferred.

Responsibilities

• Conduct comprehensive reviews of inpatient medical records.
• Identify clinical documentation gaps and opportunities for clarification.
• Develop and issue compliant physician queries.
• Evaluate clinical indicators, diagnoses, procedures, SOI/ROM and CC/MCC opportunities.
• Support accurate ICD-10-CM/PCS and DRG assignment.
• Collaborate with physicians, coders, clinical teams and other healthcare stakeholders.
• Monitor CDI quality, productivity and query performance metrics.
• Provide guidance and mentoring to CDI Specialists.
• Participate in audits, quality improvement and CDI program initiatives.
• Ensure adherence to AHIMA, ACDIS, CMS and organizational CDI standards.

Skills

Clinical judgment

Analytical skills

English communication

Epic/EHR experience

Query experience

Education

PHRN/USRN license

CDI certification (CDIP/CCDS/CIC)

3+ years clinical experience (ICU/critical care)

4+ years acute care experience (non-CC)

IP CDI experience preferred

Tools

Epic

Job description

SENIOR CLINICAL DOCUMENTATION SPECIALIST (CDI)

WHAT YOU'LL DO

• Conduct comprehensive reviews of inpatient medical records
• Identify clinical documentation gaps and opportunities for clarification
• Develop and issue compliant physician queries
• Evaluate clinical indicators, diagnoses, procedures, SOI/ROM and CC/MCC opportunities
• Support accurate ICD-10-CM/PCS and DRG assignment
• Collaborate with physicians, coders, clinical teams and other healthcare stakeholders
• Monitor CDI quality, productivity and query performance metrics
• Provide guidance and mentoring to CDI Specialists
• Participate in audits, quality improvement and CDI program initiatives
• Ensure adherence to AHIMA, ACDIS, CMS and organizational CDI standards

QUALIFICATIONS

• PHRN/USRN license.
• Minimum 3 years’ clinical experience preferably in critical care/emergency setting.
• Will consider candidates with 4+years’ clinical experience in non-critical care acute care settings.
• Prefer candidates with IP CDI experience.
• Strong knowledge of ICD-10-CM/PCS, DRGs, CC/MCCs, SOI and ROM.
• Demonstrated experience with physician queries and documentation clarification.
• Strong clinical judgment and analytical skills.
• Excellent written and verbal English communication.
• Experience with Epic or other major EHR platforms preferred.
• CDI certification such as CDIP, CCDS, or CIC is highly preferred.