RN CDI Specialist: Elevate Documentation & Compliance

R1 RCM, Inc.; Texas; On-site; USD 52,000 - 98,000; Full time

Benefits offered by this job

Competitive benefits package

Annual bonus plan

Job summary

R1 RCM Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to review inpatient medical records and identify opportunities to improve documentation quality for accurate severity of illness and reimbursement.

You will educate providers on documentation standards, collaborate with coders, and drive initiatives across CDI leadership to ensure compliant and precise coding. A US RN license and frontline CDI experience are required.

Qualifications

• Active US RN 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 electronic medical records and CDI platforms

Responsibilities

• Initiates physician interaction via query process to obtain documentation for correct coding and compliance.
• Educates physicians and staff on documentation requirements and reimbursement policies.
• Applies coding guidelines to assign working DRGs and ensure highest specificity.
• Collaborates with coders, auditors, and CDI leadership to resolve documentation issues.
• Stays updated on changes in clinical documentation standards and regulatory requirements.
• Conducts focused reviews in Mortality, PSI, and other CDI projects

Skills

CDI practices

Coding accuracy

Documentation requirements

CMS regulations

Physician query process

Collaboration with coders

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing preferred

Tools

EMR platforms

CDI platforms

Job description

R1 RCM Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to review inpatient medical records and identify opportunities to improve documentation quality for accurate severity of illness and reimbursement.

You will educate providers on documentation standards, collaborate with coders, and drive initiatives across CDI leadership to ensure compliant and precise coding. A US RN license and frontline CDI experience are required.