USRN - CDI Specalist

About the role

This is a Clinical Documentation Improvement (CDI) specialist role focused on reviewing inpatient medical records and working with healthcare teams to ensure accurate, compliant documentation and coding.

Key responsibilities

• Review inpatient medical records for documentation gaps, inconsistencies, and missing diagnoses
• Write compliant, non-leading queries to physicians to clarify documentation
• Identify CC/MCC opportunities and confirm accurate MS-DRG and APR-DRG assignment
• Validate severity of illness (SOI) and risk of mortality (ROM) documentation
• Work with coders to resolve discrepancies before final coding
• Track query responses, outcomes, and productivity metrics
• Stay current on ICD-10-CM/PCS guidelines, coding clinic updates, and CDI best practices
• Follow HIPAA requirements when handling all patient information

About you

• Bachelor of Science in Nursing (BSN)
• Active US RN license
• 2+ years of acute care clinical experience
• Med-surg, ICU, or ER experience is preferred
• 1+ year of CDI experience on a US healthcare account is preferred
• CCDS or CDIP certification is a plus
• Strong knowledge of ICD-10-CM/PCS, MS-DRG, and medical terminology