Clinical Documentation Improvement

3 months ago

Bismarck, United States Wheeler Staffing Partners Full time

Clinical Documentation Improvement (CDI) RN Specialist


Employment Type: Contract to Hire

Location: BISMARCK, ND, 58501

Sign-On Bonus: $5,000 with a 2-year commitment upon conversion to full-time

Schedule: Monday - Friday, 7:30 AM - 4:00 PM

Work Arrangement: Fully onsite during the contract period; potential for a hybrid schedule (3 days onsite, 2 days remote) after conversion and a 6-month evaluation.

Key Requirements:

  • Licenses: Active RN License in the state of North Dakota
  • Experience: Acute Care Experience (ICU, Med Surg, PICU, Tele)


Job Summary

The Clinical Documentation Improvement (CDI) Specialist is responsible for reviewing medical records to ensure accurate and complete physician documentation, supporting appropriate severity of illness, risk of mortality, and complexity of care. This role involves collaboration with various healthcare team members to enhance documentation accuracy and compliance with regulatory standards.


Essential Duties and Responsibilities

  • Record Review: Conduct initial and follow-up medical record reviews to evaluate and improve documentation accuracy for MS-DRG assignment, risk of mortality, and severity of illness.
  • Physician Queries: Formulate and resolve queries regarding unclear or conflicting health record documentation.
  • Collaboration: Work closely with case managers, nursing staff, and other ancillary staff to address documentation issues and queries before patient discharge.
  • Professional Development: Stay updated with AHA Coding and Reporting Guidelines, CMS directives, and participate in mandatory coding seminars and CDI education.
  • CDI Activities: Communicate and address CDI activities and coding issues to ensure proper follow-up and resolution.
  • Compliance and Auditing: Adhere to all vaccination and screening requirements as per client policy.


Knowledge, Skills, and Abilities

  • Strong teamwork, initiative, and time management skills
  • Advanced understanding of Medicare Part A and familiarity with Medicare Part B
  • Knowledge of disease pathophysiology, drug utilization, and MS-DRG classification
  • Proficient in critical thinking, problem-solving, and deductive reasoning
  • Excellent organizational, written, and verbal communication skills
  • Ability to work independently, whether remotely or on-site
  • Understanding of documentation strategies and improvement opportunities
  • Capable of maintaining a comprehensive auditing and monitoring program


Education and Experience

  • Education: Graduate from a Nursing program, BSN, or equivalent
  • Experience: Zero (0) to two (2) years of relevant experience in Acute Care nursing
  • Certifications: Active state Registered Nurse license; CDIP or CCDS preferred


Physical Demands and Work Environment

  • Ability to sit for extended periods and efficiently use a computer
  • Good visual acuity
  • Must be able to travel nationally as needed, not to exceed 10%


This is an excellent opportunity for a dedicated and knowledgeable CDI Specialist to join a reputable healthcare organization. If you meet the qualifications and are committed to improving clinical documentation standards, we encourage you to apply.

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