RN Nurse Clinical Documentation Improvement Specialist

R1 RCM; United States; Remote; USD 103,000 - 125,000; Full time

Job summary

R1 RCM is seeking a Clinical Documentation Improvement (CDI) Specialist with strong nursing and CDI expertise to enhance documentation quality and coding accuracy across inpatient records.

The role emphasizes physician collaboration, education on documentation standards, and timely focused reviews such as Mortality and PSI. An active RN license and prior frontline CDI experience are required, with a background in acute care settings and EMR/CDI platforms.

Qualifications

• Requires active US RN license and frontline CDI experience in an acute care hospital.
• 3–5 years of recent clinical work in the medical-surgical area, ICU, telemetry, or ED.
• Knowledge or experience in electronic medical records (EMR) platforms and CDI platforms.

Responsibilities

• Initiates physician interaction through queries and rounding to obtain complete documentation for accurate coding and reflection of CMI, LOS, and resource utilization.
• Educates physicians and staff on documentation, coding guidelines, and reimbursement policies.
• Uses coding guidelines to assign DRG with highest specificity, reviewing hospitalization records for accuracy.
• Collaborates with coders, auditors, quality improvement teams, and stakeholders to resolve documentation issues.
• Stays updated on clinical documentation standards, coding rules, and regulatory requirements.
• Conducts focused CDI reviews (Mortality, PSI, and other projects) identified by CDI leadership.

Skills

CDI practices

Front line CDI experience

RN license

Medical-surgical experience

EMR/CDI platforms

Education

Associate’s Degree in Nursing

Bachelor’s Degree in Nursing preferred

Tools

EMR platforms

CDI platforms

Job description

Compensation for this role is expected to be approximately $114,000 annually.

R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems, and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration.

As our Clinical Documentation Improvement (CDI) Specialist, you will use clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient medical records. Every day, you will evaluate the documentation of clinical services by identifying opportunities for improving the quality of medical record documentation, including focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, and other identified projects. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Participates in ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement to providers and the CDI team.

To thrive in this role, you must have the following knowledge:

• Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes, evaluation of medical record data for accuracy and reimbursement; self-motivated to stay abreast of CMS rules and regulations and incorporate those changes into daily practice.
• Front Line CDI experience in an acute care hospital
• Have an active RN license with experience in: ICU, Med surge, telemetry, or ED.

Here’s what you will experience working as a Clinical Documentation Improvement (CDI) Specialist:

• Initiates physician interaction when ambiguous, missing, or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization.
• Educates physicians and other staff on documentation requirements, coding guidelines, and reimbursement policies
• Utilizes Hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity.
• Collaborates with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues and improve coding accuracy
• Stays updated on the latest developments and changes in clinical documentation standards, coding rules, and regulatory requirements
• Conducts focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, as well as other identified projects

Required Qualifications

• Associate’s Degree in Nursing (Bachelor’s Degree in Nursing is preferred)
• An active US RN license is required
• Must have front line CDI experience in an acute care hospital
• Three to five years of recent clinical work experience in the medical-surgical area, ICU, telemetry, and or emergency department
• Knowledge or experience in electronic medical records (EMR) platforms and CDI platforms

The healthcare system is always evolving — and it’s up to us to use our shared expertise to find new solutions that can keep up. On our growing team you’ll find the opportunity to constantly learn, collaborate across groups and explore new paths for your career.

Our associates are given the chance to contribute, think boldly and create meaningful work that makes a difference in the communities we serve around the world. We go beyond expectations in everything we do. Not only does that drive customer success and improve patient care, but that same enthusiasm is applied to giving back to the community and taking care of our team — including offering a competitive benefits package.

R1 RCM Inc. (“the Company”) is dedicated to the fundamentals of equal employment opportunity. The Company’s employment practices , including those regarding recruitment, hiring, assignment, promotion, compensation, benefits, training, discipline, and termination shall not be based on any person’s age, color, national origin, citizenship status, physical or mental disability, medical condition, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status or any other characteristic protected by federal, state or local law. Furthermore, the Company is dedicated to providing a workplace free from harassment based on any of the foregoing protected categories.

If you have a disability and require a reasonable accommodation to complete any part of the job application process, please contact us at 312-496-7709 for assistance.

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To learn more, visit: R1RCM.com

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