Clinical Documentation Improvement RN

Medasource is a leading consulting and professional services firm supporting organizations across the healthcare ecosystem – including Life Sciences, RCM/Payers, Technology, Government and Nursing & Allied Health. Recognized for our commitment to our employees, consultants, and the communities we serve, we deliver solutions that drive meaningful progress across healthcare. With a nationwide footprint of 33 offices and 1,900+ active consultant placements across 120+ clients who are actively engaging Medasource talent, we continue to expand our impact as we advance the future of healthcare, one client at a time.

The Clinical Documentation Improvement (CDI) Nurse is responsible for ensuring the accuracy, completeness, and integrity of patient medical records. This role partners closely with physicians, coding teams, and clinical staff to improve documentation quality, support accurate code assignment, and ensure the medical record reflects the true severity of illness and level of care delivered. The CDI Nurse plays a critical role in optimizing reimbursement, supporting regulatory compliance, and enhancing quality reporting initiatives.

Review inpatient medical records to assess documentation accuracy, completeness, and clinical specificity Identify documentation gaps, inconsistencies, and opportunities for clarification Issue compliant queries to providers to obtain additional specificity regarding diagnoses and procedures Ensure documentation supports appropriate assignment of ICD-10-CM/PCS codes and Diagnosis Related Groups (DRGs) Collaborate with coding teams to validate clinical documentation and resolve discrepancies Monitor and impact key performance indicators such as Case Mix Index (CMI), severity of illness (SOI), and risk of mortality (ROM) Educate providers and clinical staff on documentation best practices and regulatory requirements Maintain compliance with organizational policies, CMS guidelines, and industry standards