RN CDI Specialist: Elevate Documentation & Reimbursement

R1 RCM; United States; Remote; USD 103,000 - 125,000; Full time

Job summary

R1 RCM is seeking a Clinical Documentation Improvement (CDI) Specialist with strong nursing and CDI expertise to enhance documentation quality and coding accuracy across inpatient records.

The role emphasizes physician collaboration, education on documentation standards, and timely focused reviews such as Mortality and PSI. An active RN license and prior frontline CDI experience are required, with a background in acute care settings and EMR/CDI platforms.

Qualifications

• Requires active US RN license and frontline CDI experience in an acute care hospital.
• 3–5 years of recent clinical work in the medical-surgical area, ICU, telemetry, or ED.
• Knowledge or experience in electronic medical records (EMR) platforms and CDI platforms.

Responsibilities

• Initiates physician interaction through queries and rounding to obtain complete documentation for accurate coding and reflection of CMI, LOS, and resource utilization.
• Educates physicians and staff on documentation, coding guidelines, and reimbursement policies.
• Uses coding guidelines to assign DRG with highest specificity, reviewing hospitalization records for accuracy.
• Collaborates with coders, auditors, quality improvement teams, and stakeholders to resolve documentation issues.
• Stays updated on clinical documentation standards, coding rules, and regulatory requirements.
• Conducts focused CDI reviews (Mortality, PSI, and other projects) identified by CDI leadership.

Skills

CDI practices

Front line CDI experience

RN license

Medical-surgical experience

EMR/CDI platforms

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing preferred

Tools

EMR platforms

CDI platforms

Job description

R1 RCM is seeking a Clinical Documentation Improvement (CDI) Specialist with strong nursing and CDI expertise to enhance documentation quality and coding accuracy across inpatient records.

The role emphasizes physician collaboration, education on documentation standards, and timely focused reviews such as Mortality and PSI. An active RN license and prior frontline CDI experience are required, with a background in acute care settings and EMR/CDI platforms.