Clinical Documentation Improvement Specialist (CDI) - Registered Nurse

About the role

Rome Health is seeking a Clinical Documentation Improvement Specialist – RN to support the Health Information Management Team. Reporting to the Director of Health Information Management, the specialist will use advanced clinical and coding expertise to improve the integrity of clinical documentation through review, education, and consulting. The role facilitates the overall quality, completeness, accuracy, quality of care, severity of illness, risk of mortality, and integrity of medical‑record documentation to support correct coding, reimbursement, and quality initiatives.

Responsibilities

• Utilize advanced clinical and coding expertise to direct efforts toward documentation integrity.
• Perform review, educator, and consultant functions to improve medical‑record quality.
• Ensure documentation supports accurate coding, appropriate reimbursement, and quality initiatives.
• Facilitate completeness, accuracy, and severity‑of‑illness reporting to reflect true risk of mortality.

Qualifications

• Associate in Nursing (required); Bachelor of Science in Nursing (preferred).
• Active RN license in New York State.
• Minimum 5 years of clinical experience in an acute‑care inpatient setting.

Skills

• Prior experience with Clinical Documentation Improvement (strongly preferred).
• Comfortable performing an education role and working closely with healthcare providers.
• Ability to operate independently while collaborating effectively within a team.
• Proficiency navigating Clinical Documentation Improvement software (CDE One).