Clinical Documentation Specialist Inpatient

Summary

The Inpatient Clinical Documentation Integrity (CDI) Specialist Nurse provides clinically based concurrent review of inpatient medical records to ensure accurate and complete documentation of diagnoses and procedures. The role facilitates physician and clinician documentation of patient conditions, treatments, and interventions to reflect quality of care, severity of illness, risk of mortality, and risk‑adjustment factors, supporting correct coding, reimbursement, and quality initiatives. The specialist works closely with leadership, subject‑matter experts, and operational stakeholders to remain compliant with state and federal regulatory codes and guidelines.

Schedule

Full‑time, Day Shift, 8:00 am – 4:30 pm, Monday‑Friday.

Minimum Requirements

• Current RN or LPN licensure in the State of Alabama (RN preferred).
• At least five years of nursing experience, with a minimum of three years in an acute or intensive care setting (pediatric experience preferred; CDI experience may substitute for pediatric experience).
• CCDS and/or coding certification (e.g., CPC) highly desired, or willingness to obtain after employment.

Education

Bachelor of Science in Nursing (BSN) or Associate of Science in Nursing (ASN).

Experience

Five years of staff‑level nursing experience with a specialization in acute care.

Department Overview

The Clinical Documentation Integrity (CDI) department is a key component of the Revenue Cycle, ensuring the accuracy and integrity of clinical documentation and related processes. It includes several specialized areas:

• Inpatient and Outpatient CDI: Nurses conduct concurrent and retrospective reviews of medical records to ensure documentation accurately reflects patient clinical status, severity of illness, and treatments, supporting appropriate coding, reimbursement, and compliance while providing documentation education to physicians and staff.
• Infusion Prior Authorization: Nurses manage prior‑authorization requests for outpatient infusions, including peer‑to‑peer reviews and appeals, collaborating with billing to address denials and support timely patient care.
• Medical Audit: Nurses perform chart audits to verify that hospital charges are appropriate and compliant, identifying billing trends, correcting discrepancies, and assisting departments with charge integrity.
• Medicaid Screening: Nurses focus on EPSDT and interperiodic screenings for Medicaid patients, ensuring compliance with state and federal Medicaid regulations.

Collectively, these teams support clinical excellence, regulatory compliance, and financial sustainability through comprehensive documentation and review processes.