RN - Registered Nurse - Clinical Documentation Improvement Specialist
Core
Analyze inpatient medical records to optimize clinical documentation for accurate DRG assignment, severity of illness, and risk of mortality.
Role type
Clinical Documentation Improvement Specialist (RN)
Builds
Accurate medical records and data for revenue management and quality reporting
Domain
Healthcare / Clinical Documentation
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Anatomy and Physiology knowledge, Medical record review, Query formulation, Interdisciplinary collaboration, Data trending analysis, DRG assignment logic
Preferred skills
BSN degree, Pennsylvania RN licensure
Technologies
Medical Records Systems
Responsibilities
Review inpatient medical records within 24-48 hours of admission to evaluate documentation for principal and secondary diagnoses. Formulate queries for missing, conflicting, or unclear documentation. Provide ongoing education to physicians and healthcare providers on documentation improvement. Collaborate with nursing, nutrition, pharmacy, and physicians to resolve queries prior to discharge. Participate in statistical data analysis and trending to identify improvement opportunities. Promote partnership with coding professionals to ensure accuracy of diagnoses and procedures.
Seniority
Mid-level, hands-on IC