RN - Clinical Documentation Integrity Specialist

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

Overview

Performs inpatient chart review to determine appropriate DRG assignment and assures appropriate documentation in the chart to support clinical care provided, including severity of illness and risk of mortality which impacts Case Mix Index and mortality ratings. Coordinates with physicians, nurses, ancillary staff, and the coders in Health Information Management to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG. Performs second level review of specific DRGs as assigned. Presents education related to CDI topics to peers and providers we needed or requested. Reviews DRG denials and provides information to the denials team related to appealing the encounter. Supports appropriate coding, and meets coding guidelines, regulatory and organizational standards.

Overview

Performs inpatient chart review to determine appropriate DRG assignment and assures appropriate documentation in the chart to support clinical care provided, including severity of illness and risk of mortality which impacts Case Mix Index and mortality ratings. Coordinates with physicians, nurses, ancillary staff, and the coders in Health Information Management to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG. Performs second level review of specific DRGs as assigned. Presents education related to CDI topics to peers and providers we needed or requested. Reviews DRG denials and provides information to the denials team related to appealing the encounter. Supports appropriate coding, and meets coding guidelines, regulatory and organizational standards.

Qualifications

Certifications: Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR); Certified Clinical Documentation Specialist (CCDS) within 1 year - Association of Clinical Documentation Integrity Specialists (ACDIS); Certified Coding Specialist (CCS)within 1 year - American Health Information Management Association (AHIMA); Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA); Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA); Licensed Physician (MD) - Illinois Department of Financial and Professional Regulation (IDFPR), Education: Doctorate: Medicine; College Diploma: Health Information Mgt; College Diploma: Nursing, Work Experience: CDI; Coding; Clinical bedside

Responsibilities

Conducts comprehensive, concurrent and retrospective reviews of inpatient accounts to evaluate documentation accuracy and clinical validity. To identify missing, unclear, or conflicting documentation that impacts DRG assignment, SOI/ROM, mortality, PSI, quality metrics, and clinical outcomes. Strong knowledge of ICD-10 guidelines, electronic health record (EHR) systems, and excellent communication skills to interact with physicians. Develop and issue compliant, clinically supported physician queries to clarify diagnoses, clinical indicators, or treatment plans. CDI specialist will serve as subject matter experts providing guidance and training to providers and clinicians related to DRG and documentation opportunities. Supports organizational initiatives related to quality reporting, CDI program development, and regulatory compliance. Participates in audits, data validation, and performance projects. Maintain advanced knowledge of clinical guidelines, coding updates and CDI best practices. Utilizes clinical knowledge and coding guidelines to support documentation efforts. Uses EPIC scoring tools, meets production standards, follows up on open queries according to established turnaround times. Attends mandatory and regular education sessions as needed. Follows appropriate workflow in EPIC and CDI software and notifies one up leader of any issues. May serve as an "expert" and participate in testing for upgrades as needed. Maintains educational hours needed to re-certify credentials.

About Us

Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health. Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

Find it here.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. For more information: [e-mail].

Compensation And Benefits

The compensation range for this position is $34.31per hour - $59.01per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.