RN CDI Specialist: Elevate Medical Records & Reimbursement

R1 RCM, Inc.; Butlerville (IN); On-site; USD 52,000 - 98,000; Full time

Job summary

R1 RCM, Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist.

You will perform concurrent and retrospective reviews of inpatient records, identify opportunities to improve documentation quality, and support the CDI program with physician engagement and education. Requirements include an active US RN license, front line CDI experience in an acute care hospital, and 3–5 years of clinical work in medical-surgical, ICU, telemetry, or ED settings.

Qualifications

• Must have active US RN license and front line CDI experience in an acute care hospital.
• Three to five years of recent medical-surgical, ICU, telemetry, or ED experience.
• Associate’s Degree in Nursing; bachelor’s preferred.
• Knowledge of EMR and CDI platforms.

Responsibilities

• Initiates physician interaction when documentation is ambiguous or missing and requests additional documentation for accurate coding.
• Educates physicians and staff on documentation requirements, coding guidelines, and reimbursement policies.
• Uses hospital coding sets and CDI guidelines to assign DRGs with highest specificity.
• Collaborates with coders, auditors, and quality teams to resolve documentation issues and improve accuracy.
• Keeps updated on clinical documentation standards, coding rules, and regulatory requirements.
• Conducts focused reviews in Mortality, PSI, and other CDI projects.

Skills

CDI experience

RN license

Acute care experience

Medical-surgical experience

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing preferred

Tools

EMR platforms

CDI platforms

Job description

R1 RCM, Inc. is seeking a Clinical Documentation Improvement (CDI) Specialist.

You will perform concurrent and retrospective reviews of inpatient records, identify opportunities to improve documentation quality, and support the CDI program with physician engagement and education. Requirements include an active US RN license, front line CDI experience in an acute care hospital, and 3–5 years of clinical work in medical-surgical, ICU, telemetry, or ED settings.