RN CDI Specialist: Elevate DRG & Documentation

Carle Health; Champaign (IL); On-site; USD 47,000 - 81,000; Full time

Job summary

Carle Health seeks a Certified Clinical Documentation Specialist to review inpatient records, ensure accurate DRG assignment, and document severity of illness and mortality risk. You will collaborate with physicians, nurses, and coders to collect principal and secondary diagnoses and procedures, supporting clinical care.

Responsibilities include performing concurrent and retrospective reviews, drafting physician queries, and guiding CDI activities within EPIC.

Qualifications

• Licensed RN or MD with appropriate certifications.
• Experience in CDI, coding, and clinical bedside care.
• Knowledge of ICD-10 guidelines and EHR systems.

Responsibilities

• Conduct comprehensive reviews of inpatient accounts to evaluate documentation accuracy.
• Identify missing or unclear documentation affecting DRG, SOI/ROM, and quality metrics.
• Develop physician queries to clarify diagnoses and treatment plans.
• CDI specialist will guide CDI activities and provide training to providers.
• Participate in audits, data validation, and regulatory compliance.

Skills

RN license (IL)

CCDS

CCS

RHIT

RHIA

MD license

Education

Doctorate: Medicine

College Diploma: Health Information Management

College Diploma: Nursing

Tools

EPIC

Job description

Carle Health seeks a Certified Clinical Documentation Specialist to review inpatient records, ensure accurate DRG assignment, and document severity of illness and mortality risk. You will collaborate with physicians, nurses, and coders to collect principal and secondary diagnoses and procedures, supporting clinical care.

Responsibilities include performing concurrent and retrospective reviews, drafting physician queries, and guiding CDI activities within EPIC.