Clinical Documentation Improvement Specialist
Rochester, MN
Integrated Healthcare Services
5x8 hrs, Days

RN - Level I Clinical Document Improvement Specialist
Schedule Notes
M-F 8-5

Please submit CDI pre-screening questionnaire with submissions

Location:
Remote (Anywhere within the U.S.)

Contract Length:
Not specified

Job Summary:
The Inpatient Clinical Documentation Integrity (ICDI) Specialist is responsible for reviewing patient medical records in both inpatient and outpatient settings to ensure accurate representation of severity of illness and proper coding. This role validates coding to reflect medical necessity, supports quality coding practices, and ensures documentation accurately reflects the patient's clinical status and care. The specialist utilizes advanced knowledge of disease processes, medications, and critical thinking skills to identify documentation gaps. They collaborate extensively with physicians, coding teams, case management, nursing, and other caregivers to facilitate documentation improvements. This position requires adherence to ethical and legal business procedures, compliance with federal and state regulations, and application of official coding rules and guidelines.

Required Qualifications:
- High School diploma or GED
- Two years of experience in an Inpatient Clinical Documentation Integrity Specialist (ICDIS) role
- Experience in concurrent review of medical records in the field of ICDI
- Experience in a production role within the last 12 months
- Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Registered Nurse (RN), Registered Respiratory Therapist, Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), or International/Domestic Medical Degree
- Certified Documentation Improvement Practitioner (CDIP) certification or Certified Clinical Documentation Specialist (CCDS) certification

Preferred Qualifications:
- Demonstrated skills in analytical thinking and problem solving
- Effective verbal and written communication skills
- Ability to present ideas and concepts effectively to physicians, management, and healthcare teams
- Self-motivated and able to work independently
- Ability to work flexible hours, including evenings and weekends
- Strong collaboration skills in a creative and challenging work environment

Additional Information:
This position is 100% remote and can be performed from anywhere within the U.S.