Local Contract Nurse Level I RN - Clinical Document Improvement Specialist
Rochester, MN
Integrated Healthcare Services
5x8 hrs, Days

RN - Level I Clinical Document Improvement Specialist

Location:
Remote (Can work from anywhere within the U.S.)

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 the severity of illness and facilitate proper coding. This role validates that coding reflects the medical necessity of services and ensures appropriate documentation for accurate reporting of patient conditions, risk of mortality, and complexity of care. The specialist utilizes advanced knowledge of disease processes, medications, and critical thinking skills to identify gaps in documentation. They collaborate with physicians, coding teams, case management, nursing, and other caregivers to improve clinical documentation quality. This position requires adherence to ethical and legal business procedures, compliance with federal and state regulations, and official coding standards.

Required Qualifications:
• 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.
• High School diploma or GED.
• Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Registered Nurse (RN), Registered Respiratory Therapist, Certified Coding Specialist (CCS), or Certified Coding Specialist-Physician-based (CCS-P), or International or 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 team members.
• Self-motivated and able to work independently.
• Ability to work flexible hours, including evenings and weekends, as required.
• Strong collaboration skills in a creative and challenging work environment.