Clinical Documentation Specialist RN, CDIP, CCDS

GHR is hiring an experienced CDI specialists with at least three years of recent Clinical Documentation experience. Must hold an RN certification and prefer CCDS or CDIP Certification. Proficiency with Cerner is required. Job Summary: We are seeking experienced CDI Specialists to work remotely, performing concurrent reviews of targeted inpatient medical records to ensure complete and accurate documentation. The CDI Specialist will collaborate with medical staff and utilize Cerner for documentation and reporting.

Conduct initial and subsequent concurrent reviews on selected admissions, documenting findings. Review 18-25 patient charts per day on average; corrective action plans will be implemented if productivity falls below expectations. Perform ongoing, thorough reviews of designated medical records to identify and record all conditions currently being evaluated, monitored, or treated. Assign principal and secondary diagnoses, identifying all CC/MCC, while evaluating Severity of Illness (SOI) and Risk of Mortality (ROM). Identify, flag, and escalate cases involving Patient Safety Indicators (PSI 90) and Hospital-Acquired Conditions (HAC) in the system. Complete initial patient reviews within 24-48 hours of admission and subsequent reviews every 24-48 hours as appropriate. Communicate with medical staff and caregivers as necessary via written methods to ensure complete and accurate physician documentation that reflects the patient’s severity of illness and risk of mortality. Follow AHIMA Standards of Ethical Coding, requesting clarification from providers when documentation is incomplete, conflicting, or ambiguous. Support hospital goals and objectives for compliant physician documentation in a professional and courteous manner. Adhere to hospital policies and procedures related to documentation of clinical conditions. Query the treatment team via written communication when necessary to obtain accurate and complete documentation. Apply knowledge of official coding guidelines and regulatory requirements to improve documentation quality. Utilize Cerner and Solventum’s proprietary software environment for CDI review, data entry, reporting, and query tracking.