Pediatric CDI Specialist – Documentation & ICD-10 Expert

Nemours-Children; Orlando (FL); On-site; USD 70,000 - 100,000; Full time

Job summary

Nemours is seeking a Clinical Documentation Specialist in Orlando, FL. The role involves concurrent and retrospective reviews of medical record documentation to ensure accuracy and completeness, supporting ICD-10 coding, DRG assignment, and quality reporting.

CDI works with physicians, coding, and quality teams to educate providers on risk stratification and documentation improvement. Collaboration with clinical teams to develop templates and education is essential.

Qualifications

• RN license active and unrestricted in Florida or Delaware.
• CDI certification and/or coding certification preferred.
• Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes.

Responsibilities

• Review inpatient medical records for documentation opportunities within 2 days of admission.
• Attend multidisciplinary patient rounds with care team.
• Communicate with care team regarding documentation opportunities and ICD-10 specificity.
• Develop tools and educational programs to support documentation improvement.
• Identify trends for improvement and report findings to attending group.

Skills

Medical terminology

Anatomy & physiology

Pharmacology

Disease processes

Clinical validation

Education

Active RN license in FL or DE

CDI or coding certification preferred

Job description

Nemours is seeking a Clinical Documentation Specialist in Orlando, FL. The role involves concurrent and retrospective reviews of medical record documentation to ensure accuracy and completeness, supporting ICD-10 coding, DRG assignment, and quality reporting.

CDI works with physicians, coding, and quality teams to educate providers on risk stratification and documentation improvement. Collaboration with clinical teams to develop templates and education is essential.