RN CDI Specialist: Elevate DRG Accuracy & Documentation

Cone Health; Greensboro (NC); On-site; USD 70,000 - 90,000; Full time

Job summary

The RN Clinical Documentation Specialist at Cone Health in Greensboro NC uses nursing expertise to improve documentation quality in the medical record, collaborating with providers and a multidisciplinary team to ensure accurate DRG assignment and severity of illness scoring.

Responsibilities include initiating reviews, performing queries, supporting the Clinical Documentation Improvement Program, and maintaining strong interdepartmental relationships to meet departmental goals.

Qualifications

• 3 years of experience in clinical documentation or related CDI field.
• Bachelor's degree in nursing required; RN licensure in NC or compact state.

Responsibilities

• Initiates and performs documentation review to clarify conditions and procedures.
• Ensures correct MS-DRG assignment and SOI/ROM scoring, plus identification of Hospital Acquired Conditions.
• Performs appropriate query process and supports the CDI program.
• Develops and maintains effective working relationships with colleagues and multidisciplinary teams.
• Meets established departmental goals and performs other duties as assigned.

Skills

Clinical documentation

MS-DRG assignment

SOI/ROM scoring

Interdisciplinary collaboration

Education

Bachelor's Degree in Nursing

Job description

The RN Clinical Documentation Specialist at Cone Health in Greensboro NC uses nursing expertise to improve documentation quality in the medical record, collaborating with providers and a multidisciplinary team to ensure accurate DRG assignment and severity of illness scoring.

Responsibilities include initiating reviews, performing queries, supporting the Clinical Documentation Improvement Program, and maintaining strong interdepartmental relationships to meet departmental goals.