Clinical Documentation Integrity (CDI) Specialist – RN

Job Description

We are seeking a skilled Clinical Documentation Integrity (CDI) Specialist (RN) to support accurate and complete clinical documentation in an acute care setting. This role ensures that the severity of illness, risk of mortality, and level of care are appropriately reflected in the medical record.

The CDI Specialist works collaboratively with physicians, coding teams, and multidisciplinary healthcare staff to improve documentation quality, support accurate DRG assignment, and ensure compliance with regulatory standards.

Additional Information

• Position may be classified as security-sensitive
• Equivalent qualifications require appropriate internal approval

Equal Opportunity Employer

We are an equal opportunity employer committed to creating an inclusive and diverse workplace. We do not discriminate based on race, color, religion, sex, sexual orientation, gender identity or expression, age, disability, genetic information, national origin, veteran status, or any other protected status under applicable law.

Reasonable accommodations are available throughout the hiring process and employment.

Earnings

N/A

Duties

• Perform concurrent clinical documentation reviews to ensure accuracy and completeness
• Validate acuity of care, severity of illness (SOI), and risk of mortality (ROM)
• Collaborate with physicians and healthcare teams to improve documentation quality
• Initiate compliant provider queries for clarification and specificity
• Follow up on queries to ensure documentation is completed prior to discharge
• Update CDI/DRG worksheets to reflect patient status and documentation changes
• Verify principal diagnosis (PDx) and appropriate DRG assignment
• Provide education to providers on documentation improvement opportunities
• Partner with coding and quality teams to bridge clinical and coding gaps
• Maintain quality and productivity standards
• Provide backup support for other CDI Specialists as needed
• Stay current with CDI guidelines, compliance standards, and best practices
• Perform additional duties as assigned

Requirements

• One of the following experience pathways: 3+ years acute care hospital nursing experience (preferred in ED, Trauma, or Critical Care) AND 2+ years CDI experience , OR 5+ years acute care nursing experience, including 3+ years in critical care, in lieu of CDI experience
• Proficiency with electronic health record systems
• Preferred experience with: 3M 360 Encompass and Epic EHR
• Experience working in a remote environment preferred
• Strong analytical and critical thinking skills
• High level of accuracy and attention to detail
• Excellent communication and interpersonal skills
• Ability to prioritize and manage multiple tasks effectively
• Strong problem-solving and decision-making abilities
• Ability to adapt quickly in a fast-paced clinical environment
• Knowledge of clinical documentation standards and compliance guidelines
• Self-motivated with the ability to work independently and collaboratively

Work Environment

• Remote Position
• Fast-paced, quality-driven healthcare environment

Core Values and Professional Expectations

• Commitment to problem-solving, innovation, and continuous improvement
• Demonstrates professionalism, accountability, and integrity
• Strong focus on communication, collaboration, and respect
• Team-oriented approach to delivering patient-centered care

License / Certification

• Registered Nurse (RN) license required; BSN preferred
• CCDS (Certified Clinical Documentation Specialist)
• CDIP (Certified Documentation Improvement Practitioner)