Registered Nurse, Clinical Documentation Integrity Specialist

2000 16th St, Denver, Colorado, 80202-5117, United States of America

General Purpose of the Job

The RN CDI Specialist is a detail-oriented teammate responsible for improving the quality, accuracy, and completeness of outpatient clinical documentation. This role provides expertise, education, coaching, and guidance on clinical practice and documentation to enhance clinical outcomes and optimize the capture of pertinent diagnosis codes and quality measures. The RN CDI Specialist supports risk adjustment coding, hierarchical condition category (HCC) capture, and compliance with national coding guidelines. As a facilitator within the clinical documentation integrity team, this individual collaborates with providers, coders, and healthcare professionals to ensure documentation accurately reflects the severity of illness and medical necessity. Self-directed and analytical, the RN CDI Specialist possesses advanced critical thinking, creativity, and the ability to anticipate and address opportunities and challenges in clinical documentation.

Essential Duties & Responsibilities

• Performs clinical chart reviews to ensure documentation accuracy by applying established clinical criteria for diagnosing medical conditions. (45%)
• Queries providers to clarify missing, ambiguous, or conflicting documentation in compliance with ACDIS/AHIMA query guidelines. (15%)
• Collaborates with providers and healthcare teams to ensure documentation supports risk adjustment and quality measures. (10%)
• Educates providers on best documentation practices, HCC coding, and medical necessity, to include content creation and delivery via one-on-one and group sessions. (10%)
• Content creation and delivery support compliance with CMS, HHS, and regulatory requirements for risk adjustment coding. (10%)
• Assists in tracking and reporting documentation trends to CDI leadership, identifying areas for improvement. (5%)
• Other Duties as Assigned. (5%)

Education and Requirements

• Associate's degree with a current active clinical license (RN) (required)
• 5+ years of clinical experience as a Registered Nurse (adult-geriatric or family) (preferred)
• 3+ years of clinical documentation improvement experience, coding experience, or equivalent (required)
• 1+ year of experience working with advanced practice providers as well as other clinical and non-clinical staff (required)
• Solid clinical background in evidence-based medicine, including chronic disease management and prevention.
• Experience in ICD-10 coding and documentation requirements and risk adjustment.
• Knowledge of compliant query writing/process.
• Ability to perform a comprehensive chart review of 20-30 medical records daily, with workload variations based on daily tasks.
• Technical experience using EMR systems.
• Proficiency in MS applications (Excel, Outlook, Teams, PowerPoint, Word)
• Motivated self-starter and creative problem-solver who is comfortable working in a fast-paced, dynamic environment.

Certificates, Licenses, and Registrations

• Current active clinical license (RN) without restriction in state of residence (required)
• CCDS-O or CDIP (required or must be obtained within six months of hire)
• CRC (required or must be obtained within one year of hire)

Travel and Time Requirements

• Fully remote with the ability to travel as needed to present in-person training (travel is 2-4 times per year).

Additional Requirements

Language Skills: Fluent in the written and verbal skills necessary to successfully perform the essential functions, duties, and responsibilities of the position.

Work Environment: Level III – Moderate noise (e.g., business office with computers or printers, light traffic). No required tasks involve greater exposure to blood, body fluids or tissues than would be encountered by a visitor. The normal work routine involves no exposure to blood, body fluids or other hazardous conditions.

Visual: Vision adequate to perform the essential duties/responsibilities of position.

May be required to demonstrate the ability to differentiate colors on a test strip.

Physical Demands: Physical requirements can vary. These must be reviewed with management. However, in general, the position requires the following activities:

• Ability to lift minimum of 5 lbs to a max of 50 lbs unassisted and able to stand, sit, stoop, walk, stretch, reach, and use full range of body motions.
• Manual dexterity as required for specific equipment and ability to use computer keyboard and peripherals.

The Salary Range for the role is $78,000.00 - $119,000.00 per year.