Clinical Documentation Specialist, CDI

Job Description:

• Review inpatient medical records concurrently and/or retrospectively for documentation accuracy, completeness, and compliance
• Maintain a 98% accuracy rate
• Identify opportunities to clarify diagnoses, procedures, POA indicators, severity of illness, risk adjustment, and clinical validation
• Initiate compliant physician queries for conflicting, incomplete, or nonspecific documentation
• Collaborate with coding staff to support accurate ICD-10-CM/PCS coding and MS-DRG/APR-DRG assignment
• Monitor documentation trends related to mortality, quality indicators, HACs, and PSIs
• Conduct clinical validation reviews for sepsis, respiratory failure, encephalopathy, malnutrition, acute kidney injury, and other high-risk conditions
• Maintain a 35–40% query rate, review 20–25 cases per day, and achieve 98% accuracy
• Participate in multidisciplinary rounds, provider education, and documentation improvement initiatives
• Assist with denial prevention through documentation integrity initiatives
• Stay current with CMS, ICD-10, AHA Coding Clinic, and organizational compliance standards
• Comply with corporate policies, procedures, and security standards

Requirements:

• Valid Registered Nurse license
• Bachelor’s degree or higher, completed and verified prior to start
• Seven (7) years of nursing experience
• Five (5) years of experience in the inpatient acute care setting
• Experience auditing practices, ICD 10, PCS guidelines, quality initiatives, and MS-DRG and APR DRG methodologies
• Clinical knowledge and application to coding
• Experience in CCDS, CCS, or CDIP with seven (7) years of clinical documentation/DRG validator experience
• Experience with telecommuting, EMRs, electronic tools, and current chart auditing skills
• Knowledge of Solventum HIS software portfolio, including 360 Encompass
• Proficient in Microsoft Word, Excel, PowerPoint, and other Microsoft Office programs
• Excellent verbal, written, presentation, analytical, and organizational skills
• Must be legally authorized to work in the country of employment without employment visa sponsorship

Benefits:

• Medical, Dental & Vision
• Health Savings Accounts
• Health Care & Dependent Care Flexible Spending Accounts
• Disability Benefits
• Life Insurance
• Voluntary Benefits
• Paid Absences
• Retirement Benefits
• On-site onboarding travel arrangements and related expenses paid by the company
• Relocation Assistance may be authorized

Apply To This Job