RN Nurse Clinical Documentation Improvement Specialist

Conduct clinically based concurrent and retrospective reviews of inpatient medical records to identify opportunities for improving documentation quality. Evaluate documentation for clinical conditions and procedures to support appropriate severity of illness, expected risk of mortality, and complexity of care. Initiate physician queries and participate in rounding to request additional documentation for correct coding and compliance. Facilitate focused reviews in areas identified by leadership, including Mortality reviews and PSI reviews. Educate physicians and staff on documentation requirements, coding guidelines, and reimbursement policies. Collaborate with coders, auditors, and quality teams to resolve documentation issues and improve coding accuracy. Stay updated on CMS rules, regulatory requirements, and clinical documentation standards. Assist with onboarding and training of new CDI team members.