RN CDI Specialist — Elevate Documentation & Reimbursement

R1 RCM, Inc.; Clayton (NC); On-site; USD 85,000 - 120,000; Full time

Job summary

R1 RCM, Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to improve inpatient documentation through CDI practices, coding knowledge, and CMS rule awareness.

You will conduct concurrent and retrospective reviews, collaborate with physicians and coders, and ensure accurate reflection of severity of illness and resource utilization.

Required RN license and ADN; BSN preferred, with 3–5 years’ CDI experience in an acute care setting and familiarity with EMR/CDI platforms.

Qualifications

• CDI experience in acute care required.
• Active US RN license required.
• Three to five years of clinical work in medical-surgical, ICU, telemetry or ED.

Responsibilities

• Initiates physician queries to obtain complete documentation for accurate coding and severity of illness.
• Educates physicians and staff on documentation, coding guidelines, and reimbursement policies.
• Applies coding guidelines to assign DRGs with highest specificity.
• Collaborates with coders, auditors, and quality teams to resolve documentation issues.
• Keeps updated on CDI standards, coding rules, and regulatory requirements.
• Performs mortality and PSI reviews and other identified projects.

Skills

CDI experience

RN license

Acute care nursing

EMR knowledge

Education

Associate Degree in Nursing

BSN preferred

Tools

CDI platforms

EMR platforms

Job description

R1 RCM, Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to improve inpatient documentation through CDI practices, coding knowledge, and CMS rule awareness.

You will conduct concurrent and retrospective reviews, collaborate with physicians and coders, and ensure accurate reflection of severity of illness and resource utilization.

Required RN license and ADN; BSN preferred, with 3–5 years’ CDI experience in an acute care setting and familiarity with EMR/CDI platforms.