RN Clinical Documentation Improvement Specialist
About the role
The Clinical Documentation Improvement (CDI) Specialist-RN is a registered nurse responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure complete, accurate, and compliant clinical documentation. This role focuses on supporting accurate ICD-10-CM/PCS coding, MS-DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality reporting, and reimbursement integrity. This role works closely with providers, coders, and quality teams to clarify documentation and support accurate data capture for clinical, financial, and regulatory reporting. The role applies clinical knowledge and critical thinking skills to identify documentation gaps and facilitate timely, compliant provider clarification.
Responsibilities
- Perform concurrent and retrospective reviews of inpatient medical records
- Ensure complete, accurate, and compliant clinical documentation
- Support accurate ICD-10-CM/PCS coding and MS-DRG assignment
- Assess severity of illness (SOI) and risk of mortality (ROM)
- Contribute to quality reporting and reimbursement integrity efforts
- Collaborate with providers, coders, and quality teams to clarify documentation
- Facilitate timely, compliant provider clarification for documentation gaps
Requirements
- Associate’s Degree in Nursing (ASN) or Nursing Diploma
- Valid NYS RN licensure or eligible
- Working knowledge of encoding systems and Excel
Preferred Qualifications
- Bachelor’s Degree in Nursing (BSN)
- Previous coding experience
- CCS (Certified Coding Specialist) – AHIMA
- CIC (Certified Inpatient Coder) – AAPC
- CCDS (Certified Clinical Documentation Specialist) – ACDIS
Schedule
Primary work shift: Day; Regular scheduled weekly hours: 40
Pay
Compensation range: $37.00 – $55.50 per hour, depending on experience