The Clinical Documentation Improvement (CDI) Specialist
RN is a registered nurse responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure complete, accurate, and compliant clinical documentation. This role focuses on supporting accurate ICD 10 CM/PCS coding, MS DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity. This role works closely with providers, coders, and quality teams to clarify documentation and support accurate data capture for clinical, financial, and regulatory reporting. This role applies clinical knowledge and critical thinking skills to identify documentation gaps and facilitate timely, compliant provider clarification. Education/ExperienceMinimum Required:Associate’s Degree in Nursing (ASN) or Nursing Diploma.Preferred:Bachelor’s Degree in Nursing (BSN).Working knowledge of encoding system and Excel.Previous Coding experience.License/CertificationMinimum Required:Valid NYS RN licensure or eligible.Preferred:CCS (Certified Coding Specialist) – AHIMACIC (Certified Inpatient Coder)
AAPCCCDS (Certified Clinical Documentation Specialist)–ACDIS Work EnvironmentMay be remote, hybrid, or onsite depending on facility needs.Requires prolonged periods of computer use and attention to detail.The office is air conditioned as well as heated.Age of Patients ServedNot ApplicableHIPAA Roles
Based Access to Patient InformationAll – Access to patient information, including restricted information – Level 4
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