RN Clinical Documentation & CDI Specialist

Valley Medical Center & Clinics; Renton (WA); On-site; USD 95,000 - 142,000; Full time

Job summary

Valley Medical Center & Clinics in Renton, WA is seeking a Clinical Documentation Specialist to ensure the medical record accurately reflects the patient’s clinical condition, severity of illness, risk of mortality, quality outcomes, and services provided.

The role serves as a liaison between providers, coding, case management, quality, and revenue cycle teams to improve documentation accuracy and billing compliance.

Qualifications

• Current unrestricted RN license in the State of Washington.
• Five years of RN experience in acute care, or three years with inpatient CDI experience.
• CCDS or CCDS-O certification strongly preferred; EPIC experience required.

Responsibilities

• Conduct comprehensive reviews of electronic medical records to ensure complete, accurate documentation reflecting SOI/ROM and quality indicators.
• Assign working APR-DRG and severity level, and perform follow-up reviews per LOS standards.
• Collaborate to resolve CDI-coder DRG discrepancies and communicate improvements.
• Identify documentation gaps and opportunities for improvement to support compliant coding.
• Educate physicians and staff on documentation requirements and improvement opportunities.
• Maintain proficiency in coding guidelines, reimbursement methodologies, and regulatory requirements.

Job description

Valley Medical Center & Clinics in Renton, WA is seeking a Clinical Documentation Specialist to ensure the medical record accurately reflects the patient’s clinical condition, severity of illness, risk of mortality, quality outcomes, and services provided.

The role serves as a liaison between providers, coding, case management, quality, and revenue cycle teams to improve documentation accuracy and billing compliance.