RN CDI Specialist: Elevate DRG & Documentation

Capital Health (US); Lawrenceville (NJ); On-site; USD 82,000 - 107,000; Full time

Benefits offered by this job

Medical Plan

Prescription drug coverage

Dental Plan

Vision Plan

Flexible Spending Account (FSA)

Retirement Savings Plan

Paid Time Off

Job summary

Capital Health is seeking a full-time Clinical Documentation Improvement (CDI) Specialist to enhance documentation quality and DRG accuracy across hospital units. You will interact with physicians, nurses, and coding staff to obtain complete documentation.

Requirements include RN license and CDI/coding experience; CCDS/CDIP credentials are preferred. This role emphasizes collaboration, education, and ongoing process improvement within Medical Records.

Qualifications

• RN licensed with current registration.
• Two years’ ICU/Medical-Surgical experience or three years related CDI/coding experience in hospital.
• CCD(CDS) or CDIP credential preferred.

Responsibilities

• Initial reviews of patient records within 24-48 hours to evaluate documentation for accurate DRG.
• Follow-up reviews every 2-3 days to support final DRG assignment at discharge.
• Query physicians for missing or unclear documentation.
• Educate care teams on CDI guidelines and documentation requirements.
• Collaborate with coding staff to ensure data accuracy and completeness.

Skills

Clinical documentation improvement

Medical coding

EMR systems

Clear communication

Education

RN license

BSN preferred

CCDS/CDIP preferred

Tools

EMR software

Job description

Capital Health is seeking a full-time Clinical Documentation Improvement (CDI) Specialist to enhance documentation quality and DRG accuracy across hospital units. You will interact with physicians, nurses, and coding staff to obtain complete documentation.

Requirements include RN license and CDI/coding experience; CCDS/CDIP credentials are preferred. This role emphasizes collaboration, education, and ongoing process improvement within Medical Records.