RN CDI Specialist: Elevate Clinical Documentation & Coding

R1 RCM, Inc.; Lexington (KY); On-site; USD 52,000 - 98,000; Full time

Benefits offered by this job

Annual bonus plan (5% target)

Job summary

R1 RCM Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to review inpatient medical records, identify documentation gaps and support appropriate severity of illness and reimbursement.

You will use clinical and coding knowledge to drive accuracy and quality across CDI initiatives. Key responsibilities include engaging physicians for documentation clarity, educating staff on coding guidelines, applying DRG concepts, and collaborating with coders and quality teams to improve

Qualifications

• Associate’s degree in Nursing is required; Bachelor's degree preferred.
• Active RN license required.
• Three to five years of clinical work in medical-surgical, ICU, telemetry or ED.
• Front line CDI experience in an acute care hospital.

Responsibilities

• Initiates physician interaction to obtain documentation for correct coding and compliance.
• Educates physicians and staff on documentation requirements and reimbursement guidelines.
• Applies DRG concepts and CMS guidelines to ensure highest specificity in coding.
• Collaborates with coders, auditors, quality teams, and CDI leadership to resolve documentation issues.
• Stays updated on clinical documentation standards and regulatory changes.

Skills

CDI practices

RN license

Inpatient coding

Education

Associate’s Degree in Nursing

Tools

EMR platforms

CDI platforms

Job description

R1 RCM Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to review inpatient medical records, identify documentation gaps and support appropriate severity of illness and reimbursement.

You will use clinical and coding knowledge to drive accuracy and quality across CDI initiatives. Key responsibilities include engaging physicians for documentation clarity, educating staff on coding guidelines, applying DRG concepts, and collaborating with coders and quality teams to improve