Senior Clinical Documentation Specialist

Nebraska Medicine; United States; Hybrid; USD 90,000 - 110,000; Full time

Job summary

Nebraska Medicine seeks a Clinical Documentation Improvement (CDI) Specialist to join our team. The role involves extensive record review to ensure compliant documentation, accurate illness severity representation, and collaboration with clinicians, HIM, and nursing staff.

Required are a BSN and RN license (Nebraska or compact state). Previous CDI or inpatient acute care experience is valued, with opportunities for professional development in a respected academic health network.

Qualifications

• Two years bedside inpatient acute care experience or recent CDI Specialist experience; RHIA/RHIT/CCS with 3+ years acceptable.
• BSN required.
• Critical thinking, problem solving, and deductive reasoning skills required.
• Proficient in Microsoft Word, Excel, Outlook and EMR systems.
• Outstanding organizational, analytical, writing, and interpersonal skills with diverse stakeholders.
• Current Nebraska RN license or compact state license required.

Responsibilities

• Perform extensive record review to ensure compliant documentation and accurate severity of illness representation.
• Collaborate with clinicians, HIM professionals, and nursing staff to support CDI processes and documentation integrity.

Skills

Critical thinking

Problem solving

Deductive reasoning

Interpersonal skills

Attention to detail

Education

BSN (Bachelor of Science in Nursing)

RN license in Nebraska or compact state

RHIA/RHIT/CCS credential (preferred)

Tools

Microsoft Word

Microsoft Excel

Outlook

Job description

Nebraska Medicine seeks a Clinical Documentation Improvement (CDI) Specialist to join our team. The role involves extensive record review to ensure compliant documentation, accurate illness severity representation, and collaboration with clinicians, HIM, and nursing staff.

Required are a BSN and RN license (Nebraska or compact state). Previous CDI or inpatient acute care experience is valued, with opportunities for professional development in a respected academic health network.