RN CDI Specialist — Clinical Documentation & Coding Quality

R1 RCM, Inc.; Fulton (MS); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Annual bonus plan

Competitive benefits package

Job summary

R1 is seeking a Clinical Documentation Improvement (CDI) Specialist to apply clinical and coding knowledge in concurrent and retrospective reviews of inpatient records. You will identify opportunities to improve documentation quality and support appropriate severity of illness and complexity of care of the patient.

You will collaborate with physicians and coders, educate staff on documentation and coding guidelines, stay updated on CMS rules, and participate in projects such as Mortality and PSI

Qualifications

• Associate’s Degree in Nursing required; Bachelor’s preferred.
• Active US Registered Nurse license required.
• Front line CDI experience in an acute care hospital.
• 3–5 years of recent clinical work in medical-surgical, ICU, telemetry, or ED.
• Knowledge of EMR and CDI platforms.

Responsibilities

• Initiates physician interaction to obtain documentation for accurate coding and reflection of CMI, LOS, and resource use.
• Educates physicians and staff on documentation, coding guidelines, and reimbursements.
• Assigns DRGs using coding guidelines to ensure highest specificity.
• Collaborates with coders, auditors, and QA to resolve documentation issues.
• Stays updated on clinical documentation standards and regulatory changes.
• Performs mortality and PSI reviews and other identified projects.

Skills

CDI knowledge

RN license

Acute care CDI experience

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing preferred

Tools

EMR platforms

CDI platforms

Job description

R1 is seeking a Clinical Documentation Improvement (CDI) Specialist to apply clinical and coding knowledge in concurrent and retrospective reviews of inpatient records. You will identify opportunities to improve documentation quality and support appropriate severity of illness and complexity of care of the patient.

You will collaborate with physicians and coders, educate staff on documentation and coding guidelines, stay updated on CMS rules, and participate in projects such as Mortality and PSI