The Clinical Documentation Integrity Registered Nurse (CDI RN) will serve as the CDI Nurse Advisor responsible for reviewing inpatient and outpatient medical records to ensure the clinical documentation accurately reflects the patient’s severity of illness, risk of mortality, and the care provided. This role collaborates with providers and clinical teams to support documentation accuracy, compliance, and appropriate reimbursement.

REQUIREMENTS:

• Active RN license, eligible to practice independently in a hospital setting.
• Minimum 2 years of CDI experience.
• Certification from AHIMA, AAPC, or ACDIS is required.
• Knowledge of ICD-10-CM/PCS, MS-DRG, coding compliance, and CDI query guidelines.
• Strong communication, clinical judgment, and critical thinking skills.
  Job Type: Full-time
  Pay: $28.00 - $31.00 per hour
  Work Location: In perso

• Review patient records to validate clinical accuracy and completeness of documentation.
• Identify documentation gaps and initiate provider queries to ensure compliance.
• Collaborate with physicians, HIM coding staff, quality analysts, and revenue cycle teams.
• Provide education to providers and staff on best practices in documentation and coding.
• Participate in clinical validation, mortality reviews, and quality initiatives (CMS, HEDIS, Joint Commission).
• Assist in SOP development and process improvement initiatives.
• Conduct audits and reconcile CDI and coding discrepancies (MS-DRG, SOI/ROM).