RN CDI Specialist: Elevate Documentation & Reimbursement

Socket.dev; Indiana (PA); Hybrid; USD 103,000 - 125,000; Full time

Job summary

R1 RCM Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to perform concurrent and retrospective reviews of inpatient records, focusing on accurate documentation and coding to optimize severity, LOS and reimbursement. An active RN license and frontline CDI experience are required.

You will educate staff on documentation guidelines, collaborate with coders and CDI leadership, and stay current with CMS rules and CDI standards as part of ongoing improvement initiatives.

Qualifications

• CDI knowledge and documentation for quality outcomes and CMS rules.
• Frontline CDI experience in acute care hospitals.
• Active US RN license with ICU/telemetry/ED experience.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient records to improve documentation and coding accuracy.
• Educate physicians and staff on documentation, coding guidelines, and reimbursement policies.
• Assign working DRG using coding guidelines and hospital policies; ensure highest specificity.
• Collaborate with coders, auditors, and CDI team to resolve documentation issues.

Skills

CDI practices

Coding knowledge

Documentation requirements

Frontline CDI experience

RN license

EMR platforms

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

EMR platforms

Job description

R1 RCM Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to perform concurrent and retrospective reviews of inpatient records, focusing on accurate documentation and coding to optimize severity, LOS and reimbursement. An active RN license and frontline CDI experience are required.

You will educate staff on documentation guidelines, collaborate with coders and CDI leadership, and stay current with CMS rules and CDI standards as part of ongoing improvement initiatives.