RN CDI Specialist—Elevate Medical Documentation Quality

R1 RCM, Inc.; Indiana; On-site; USD 52,000 - 98,000; Full time

Job summary

R1 RCM Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to conduct concurrent and retrospective reviews of inpatient medical records, ensuring accurate severity of illness, resource use, and documentation quality.

You will drive physician engagement and optimize documentation across the patient care continuum. The role requires active RN licensure, frontline CDI experience in acute care, and 3–5 years of clinical work in medical-surgical, ICU, telemetry, or ED settings.

Qualifications

• CDI practices, coding, and documentation requirements with CMS rule updates.
• Front line CDI experience in an acute care hospital.
• Active US RN license required.
• 3–5 years clinical work in medical-surgical, ICU, telemetry or ED.

Responsibilities

• Initiates physician interaction through queries and rounding to obtain documentation for accurate coding and CMI reflection.
• Educates physicians and staff on documentation, coding guidelines, and reimbursement policies.
• Applies coding guidelines to assign working DRG and reviews records to ensure highest specificity of codes.
• Collaborates with coders, auditors, and quality teams to resolve documentation issues.
• Stays updated on clinical documentation standards, coding rules, and regulatory requirements.
• Performs focused reviews in Mortality, PSI, and other CDI projects.

Skills

CDI practices

Coding

Documentation requirements

RN license

Front line CDI experience

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing

Tools

EMR platforms

CDI platforms

Job description

R1 RCM Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist to conduct concurrent and retrospective reviews of inpatient medical records, ensuring accurate severity of illness, resource use, and documentation quality.

You will drive physician engagement and optimize documentation across the patient care continuum. The role requires active RN licensure, frontline CDI experience in acute care, and 3–5 years of clinical work in medical-surgical, ICU, telemetry, or ED settings.