Specialist

Insight Global; United States; On-site; USD 85,000 - 110,000; Full time

Job summary

Insight Global is seeking a Clinical Documentation Improvement Specialist to review clinical documentation for accuracy and regulatory compliance in inpatient settings. You will work with physicians and staff to clarify documentation, perform PDX shifting when appropriate, and identify CDI opportunities to improve reimbursement while supporting quality metrics and compliance initiatives.

Applicants should hold an active RN license and have 2+ years of CDI experience in inpatient acute care

Qualifications

• Active RN license required.
• 2+ years CDI experience in inpatient acute care within last 5 years.
• Hands-on PDX shifting to reflect patient conditions.
• Ability to identify CDI opportunities independently.
• Strong physician queries formulation skills.
• Ability to meet productivity metrics and respond to feedback.

Responsibilities

• Review clinical documentation for accuracy, completeness and regulatory compliance.
• Work directly with physicians and clinical staff to clarify documentation.
• Collaborate with coding and revenue cycle teams.
• Identify opportunities for documentation improvement and reimbursement optimization.
• Support quality metrics and compliance initiatives.
• Maintain ongoing professional development and respond to feedback.

Skills

Clinical Documentation Improvement

PDX shifting

Physician queries

Inpatient acute care experience

Regulatory/compliance knowledge

Collaborative work with physicians

Productivity metrics

Feedback implementation

Education

Registered Nurse (RN) license

Tools

3M coding software

Job description

Review clinical documentation to ensure accuracy, completeness, and regulatory compliance.

Work directly with physicians and clinical staff to clarify documentation.

Perform Primary Diagnosis (PDX) shifting when appropriate to accurately reflect patient conditions and severity.

Identify opportunities for documentation improvement and reimbursement optimization

Collaborate with coding and revenue cycle teams.

Support quality metrics and compliance initiatives.

Active RN license required

2+ years of CDI experience within inpatient acute care in the last 5 years

Must be able to demonstrate hands-on PDX shifting

Understand when the primary diagnosis should be changed to a more appropriate diagnosis

Must be able to identify CDI opportunities independently

Strong ability to formulate appropriate physician queries

Cannot depend solely on 3M to identify opportunities or formulate the query

Candidates cannot be working another job simultaneously

Ability to take and implement feedback

Strong clinical background, with ICU, charge nurse, or bedside nursing experience being valuable

Ability to identify documentation opportunities and independently formulate queries

Ability to consistently meet required productivity metrics