RN Clinical Documentation Specialist (CDI)

Jobtome; Albuquerque (NM); On-site; USD 70,000 - 98,000; Full time

Job summary

Jobtome is seeking a full-time Clinical Documentation Improvement (CDI) Specialist to review inpatient medical records during hospitalization, ensuring accurate documentation and appropriate DRG assignment. You will query physicians, coordinate with care teams, and drive documentation quality improvements to reflect severity of illness and resource use.

The role requires RN licensure in NM or via reciprocal agreement, with at least 1 year of relevant experience and familiarity with coding

Qualifications

• Essential education includes program graduate status.
• Nonessential: bachelor's degree optional.

Responsibilities

• REVIEW - identify principal and secondary diagnoses and assign a working MS-DRG.
• CONCURRENT REVIEW - perform initial and ongoing reviews for admissions.
• PROBLEM SOLVING - interpret clinical data and communicate documentation needs to physicians.
• ABSTRACTS - track and report quality indicators and documentation progress.
• COMMUNICATION - obtain/clarify diagnoses and comorbidities with physicians.
• COORDINATION - facilitate communication between HIM, Utilization Review, Quality Management and physicians.
• PROCESS IMPROVEMENT - develop and monitor improvement plans.
• REPORTS - assist with physician profiling reports for the CDI program.
• REPORT ANALYSIS - analyze documentation for severity of illness and outcomes.
• EDUCATION - provide education to physicians and staff on documentation.
• CONFIDENTIALITY - maintain HIPAA compliance.
• OTHER - perform additional duties.
• COMPLIANCE - use query tools to capture documentation supporting severity and mortality risk

Education

Program Graduate

Bachelor's Degree

Job description

Jobtome is seeking a full-time Clinical Documentation Improvement (CDI) Specialist to review inpatient medical records during hospitalization, ensuring accurate documentation and appropriate DRG assignment. You will query physicians, coordinate with care teams, and drive documentation quality improvements to reflect severity of illness and resource use.

The role requires RN licensure in NM or via reciprocal agreement, with at least 1 year of relevant experience and familiarity with coding