RN – Clinical Documentation Integrity Specialist
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Job Description
RN CDI Specialist reviewing inpatient records, clarifying diagnoses, and supporting DRG accuracy for Carle Health. Educating clinicians and contributing to coding, quality, and compliance initiatives.
Responsibilities:
- Performs inpatient chart review to determine appropriate DRG assignment and ensure documentation supports clinical care, severity of illness, and risk of mortality
- Coordinates with physicians, nurses, ancillary staff, and Health Information Management coders to identify and record diagnoses, procedures, and working DRGs
- Performs second-level review of assigned DRGs
- Provides education on CDI topics to peers, providers, and clinicians
- Reviews DRG denials and provides information to the denials team for appeals
- Conducts comprehensive, concurrent, and retrospective reviews of inpatient accounts
- Identifies missing, unclear, or conflicting documentation affecting DRG assignment, SOI/ROM, mortality, PSI, quality metrics, and clinical outcomes
- Develops and issues compliant, clinically supported physician queries
- Provides guidance and training to providers and clinicians on DRG and documentation opportunities
- Supports quality reporting, CDI program development, and regulatory compliance initiatives
- Participates in audits, data validation, and performance projects
- Uses EPIC and CDI software workflows, follows up on open queries, and reports issues to leadership
- Participates in testing upgrades as an expert when needed
- Attends required education sessions
Requirements:
- Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
- Certified Clinical Documentation Specialist (CCDS) within 1 year - Association of Clinical Documentation Integrity Specialists (ACDIS)
- Certified Coding Specialist (CCS) within 1 year - American Health Information Management Association (AHIMA)
- Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA)
- Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)
- Licensed Physician (MD) - Illinois Department of Financial and Professional Regulation (IDFPR)
- Doctorate: Medicine
- College Diploma: Health Information Mgt
- College Diploma: Nursing
- Work experience in CDI, coding, or clinical bedside care
- Strong knowledge of ICD-10 guidelines
- Knowledge of electronic health record (EHR) systems
- Excellent communication skills to interact with physicians
- Advanced knowledge of clinical guidelines, coding updates, and CDI best practices
- Ability to support documentation efforts using clinical knowledge and coding guidelines
- Ability to use EPIC scoring tools and CDI software
- Ability to meet production standards and established query turnaround times
- Ability to maintain educational hours needed to re-certify credentials
Benefits:
- Comprehensive benefits package
- Day shift schedule, Monday-Friday
- No holiday requirements
- No on-call requirements
- Opportunities for growth and life-long careers
- Equal opportunity employment
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