Senior Inpatient CDI Nurse | Documentation & Coding Expert

ACDIS Pediatric Networking Group; United States; À distance; USD 80 000 - 110 000; Plein temps

Résumé du poste

ACDIS Pediatric Networking Group is seeking a Senior Clinical Documentation Specialist (CDI) to review inpatient records, identify documentation gaps, and develop compliant physician queries. You will evaluate diagnoses, procedures, and DRG opportunities, support ICD-10-CM/PCS coding, and collaborate with physicians, coders, and clinical teams to drive quality metrics.

Applicants should hold a nursing license (PHRN/USRN), have 3–4+ years clinical experience (ICU preferred) or 4+ years in

Qualifications

• PHRN/USRN license and CDI credentials.
• 3+ years clinical experience; critical care or emergency preferred.
• IP CDI experience preferred; 4+ years in acute care acceptable.
• Strong ICD-10-CM/PCS, DRG, CC/MCC, SOI and ROM knowledge.
• Experience with physician queries and documentation clarification.
• Excellent written and verbal English communication.
• Epic or major EHR platform experience preferred.
• CDI certification (CDIP, CCDS, CIC) highly preferred.

Responsabilités

• Conduct comprehensive reviews of inpatient medical records.
• Identify clinical documentation gaps and opportunities for clarification.
• Develop and issue compliant physician queries.
• Evaluate clinical indicators, diagnoses, procedures, SOI/ROM and CC/MCC opportunities.
• Support accurate ICD-10-CM/PCS and DRG assignment.
• Collaborate with physicians, coders, clinical teams and other healthcare stakeholders.
• Monitor CDI quality, productivity and query performance metrics.
• Provide guidance and mentoring to CDI Specialists.
• Participate in audits, quality improvement and CDI program initiatives.
• Ensure adherence to AHIMA, ACDIS, CMS and organizational CDI standards.

Connaissances

Clinical judgment

Analytical skills

English communication

Epic/EHR experience

Query experience

Formation

PHRN/USRN license

CDI certification (CDIP/CCDS/CIC)

3+ years clinical experience (ICU/critical care)

4+ years acute care experience (non-CC)

IP CDI experience preferred

Outils

Epic

Description du poste

ACDIS Pediatric Networking Group is seeking a Senior Clinical Documentation Specialist (CDI) to review inpatient records, identify documentation gaps, and develop compliant physician queries. You will evaluate diagnoses, procedures, and DRG opportunities, support ICD-10-CM/PCS coding, and collaborate with physicians, coders, and clinical teams to drive quality metrics.

Applicants should hold a nursing license (PHRN/USRN), have 3–4+ years clinical experience (ICU preferred) or 4+ years in