RN CDI Specialist — Clinical Documentation Improvement

Capital Health; Trenton (NJ); On-site; USD 54,277 - 70,905; Full time

Benefits offered by this job

Medical Plan

Dental Plan

Vision Plan

Commuter Transit

Job summary

Capital Health is seeking a Clinical Document Improvement Specialist to lead CDI efforts in Trenton, NJ. You will review records, query physicians, and ensure accurate DRG assignment and documentation of severity and mortality risk.

The role requires an RN, with preferred CCDS/CDIP certification and 2+ years in acute care or 3+ years in CDI/coding in a hospital setting. Excellent communication and analytical skills are essential.

Qualifications

• RN required (Graduate of an accredited nursing program).
• BSN preferred.
• CCDS or CDIP preferred.
• 2 years’ acute care experience or 3 years CDI/coding in hospital setting.

Responsibilities

• Completes initial reviews of patient records within 24-48 hours to determine principal/secondary diagnoses and procedures for accurate DRG.
• Performs follow-up reviews every 2-3 days to support DRG assignment at discharge.
• Queries physicians to obtain missing or unclear documentation.
• Educates care team on CDI guidelines and documentation quality.
• Collaborates with coding staff to ensure accurate data for DRG, severity, and risk of mortality.

Skills

Critical thinking

Verbal & written communication

Clinical knowledge

EMR systems proficiency

Education

RN

BSN preferred

Tools

CDI/CDIP tools

Job description

Capital Health is seeking a Clinical Document Improvement Specialist to lead CDI efforts in Trenton, NJ. You will review records, query physicians, and ensure accurate DRG assignment and documentation of severity and mortality risk.

The role requires an RN, with preferred CCDS/CDIP certification and 2+ years in acute care or 3+ years in CDI/coding in a hospital setting. Excellent communication and analytical skills are essential.