RN CDI Nursing Specialist – Clinical Documentation

Lexingtononcology; Columbia (SC); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Day ONE benefits

FSAs

403(b) match

Life insurance

Supplemental life

Adoption assistance

Disability coverage

Student loan forgiveness

Job summary

Lexington Health in West Columbia, SC, seeks a skilled Clinical Documentation Improvement Specialist to conduct thorough concurrent reviews of medical records, capturing principal and secondary diagnoses and procedures to support accurate DRG assignment.

Collaborate with physicians, nurses, and case managers to clarify documentation, ensure compliance, and identify MCCs/CCs, PSI, and mortality indicators. Requires RN license in SC and CCDS/CDIP certification or eligibility within 2 years.

Qualifications

• RN license to practice in South Carolina required.
• Associate’s Degree in Nursing required.
• Certification from ACDIS (CCDS) or AHMIA (CDIP) or eligible within 2 years.
• Experience in acute care and concurrent medical record reviews preferred.

Responsibilities

• Collaborate with physicians, nurses, and case managers to identify diagnosis options and DRGs.
• Clarify documentation needs using effective written/verbal communication.
• Review records to identify MCCs/CCs, PSI, HAC, and patient severity of illness.
• Maintain confidentiality of patient information and documentation.

Skills

Clinical documentation

ACDIS knowledge

Communication skills

Confidentiality

Education

Associate’s Degree in Nursing

Tools

ICD-10-CM

ICD-10-PCS

AHA Coding Clinics

CMS Guidelines

Job description

Lexington Health in West Columbia, SC, seeks a skilled Clinical Documentation Improvement Specialist to conduct thorough concurrent reviews of medical records, capturing principal and secondary diagnoses and procedures to support accurate DRG assignment.

Collaborate with physicians, nurses, and case managers to clarify documentation, ensure compliance, and identify MCCs/CCs, PSI, and mortality indicators. Requires RN license in SC and CCDS/CDIP certification or eligibility within 2 years.