RN – Clinical Documentation Integrity Specialist

This is a fully remote position, open to applicants in Illinois.

📋 Description

• Conduct inpatient chart assessments to ensure accurate DRG classification

• Verify that documentation reflects clinical care, illness severity, and mortality risk

• Collaborate with physicians, nurses, ancillary staff, and Health Information Management coders

• Identify and document principal and secondary diagnoses and procedures

• Assign working DRGs and perform second-level reviews of selected DRGs and inpatient cases

• Clarify medical record documentation through communication with providers and staff

• Record findings and encounter status using Carle CDI software

• Adhere to query processes and escalate issues as necessary

• Provide education to peers and providers on CDI-related topics

• Review DRG denials and create appeal letters

• Attend mandatory and regular educational sessions

• Follow workflows in EPIC and CDI software, reporting issues to the supervising leader

• Engage in testing software updates as required

⛳️ Requirements

• Minimum of 2 years of experience in Clinical Documentation

• At least 2 years of Nursing experience

• Registered Health Information Administrator (RHIA) certification from AHIMA

• Current Licensed Registered Professional Nurse (RN) in Illinois

• Associate's Degree in a relevant field

• Experience in clinical bedside care

• Experience in CDI

• Availability to work Monday–Friday, 8 a.m.–5 p.m., with occasional weekends

🏝️ Benefits

• Comprehensive benefits package

• Equal Opportunity Employer

• Opportunities for growth and long-term careers