Registered Nurse - Clinical Document Improvement Specialist

About the role

Registered Nurse (RN) Clinical Document Improvement Specialist responsible for reviewing inpatient medical records to ensure complete, accurate, and compliant documentation.

Responsibilities

• Perform concurrent and retrospective reviews
• Support accurate coding and DRG assignment
• Identify documentation gaps
• Collaborate with providers, coders, and quality teams to clarify documentation for clinical, financial, and regulatory purposes
• Review medical records
• Support accurate documentation
• Facilitate provider clarification
• Ensure compliance with coding and reporting standards
• Ensure HIPAA compliance and appropriate access to patient information

Qualifications

• Minimum associate’s degree in nursing (preferred bachelor’s degree)
• Valid NYS RN licensure or eligibility
• Knowledge of encoding systems, Excel, and previous coding experience advantageous
• Preferred certifications: CCS, CIC, or CCDS

Skills

• Strong clinical knowledge
• Critical thinking
• Attention to detail
• Ability to work independently in various environments (remote, hybrid, onsite)

Benefits

• Health insurance
• Dental insurance
• Vision insurance
• Retirement plans
• Education reimbursement
• Wellness programs

Supports professional growth and work-life balance.