RN CDI Specialist - Drive DRG Accuracy & Care Quality

Capital-Health; Princeton (NJ); On-site; USD 82,000 - 107,000; Full time

Benefits offered by this job

Medical Plan

Retirement Plan

Paid Time-Off

Life Insurance

Disability Benefits

Job summary

Capital Health seeks a Clinical Documentation Specialist to improve the completeness and accuracy of clinical documentation across our hospitals and outpatient services. You will work with physicians, nursing staff, and HIM colleagues to ensure DRG assignments reflect patient complexity.

Review records within 24–48 hours, conduct follow-ups, and query for clarification. Education of care teams on documentation guidelines is a key focus, with CCDS/CDIP preferred.

Qualifications

• RN, required; BSN preferred.
• CCDS or CDIP credential preferred.
• Two years’ clinical experience or three years coding/clinical documentation experience.

Responsibilities

• Completes initial reviews within 24–48 hours to assign DRG and LOS.
• Conducts follow-up reviews every 2–3 days through discharge.
• Queries physicians for missing or unclear documentation.
• Educates physicians and care teams on documentation guidelines.
• Collaborates with coding professionals to ensure data accuracy.
• Supports pre-bill / post-bill reviews to address documentation gaps.

Skills

Clinical documentation

Critical thinking

Verbal & written communication

EMR systems

Coding knowledge

Team collaboration

Education

RN, required

BSN preferred

CCDS or CDIP credential preferred

Tools

EMR software

Encoding software

Windows-based software

Job description

Capital Health seeks a Clinical Documentation Specialist to improve the completeness and accuracy of clinical documentation across our hospitals and outpatient services. You will work with physicians, nursing staff, and HIM colleagues to ensure DRG assignments reflect patient complexity.

Review records within 24–48 hours, conduct follow-ups, and query for clarification. Education of care teams on documentation guidelines is a key focus, with CCDS/CDIP preferred.