Clinical Documentation Improvement Specialist

R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems, and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration. Overview As our CDI Specialist, you will use clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient medical records. Each day, you will evaluate the documentation of clinical services by identifying opportunities to improve the quality of medical record documentation, including focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, and other identified projects. You will facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. You will participate in ongoing documentation improvement initiatives, including formal and informal education plans related to clinical documentation improvement to providers and the CDI team. Responsibilities To thrive in this role, you must have the following knowledge: Highly skilled in CDI practices, coding, and documentation requirements related to quality outcomes, evaluation of medical record data for accuracy and reimbursement; self-motivated to stay abreast of CMS rules and regulations and incorporate those changes into daily practice. Possess flexibility to work in a fast-paced and dynamic environment Ability and willingness to learn other applications such as electronic calendar, MS Teams, MS SharePoint, One Drive, CDE One, and other CDI platforms Effective interpersonal skills Takes initiative, works independently, is self-directed, and highly motivated in work areas Ability to resolve moderate to high complexity issues Basic computer skills to include Word, Excel, PowerPoint, and Outlook/email Ability to effectively provide and receive feedback, both positive and constructive. Excellent judgment and self-motivation, experience working independently with minimal supervision. Demonstrated judgment, critical thinking, and independent decision-making What you will experience Initiates physician interaction when ambiguous, missing, or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization. Educates physicians and other staff on documentation requirements, coding guidelines, and reimbursement policies Utilizes hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity. Collaborates with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues and improve coding accuracy Stays updated on the latest developments and changes in clinical documentation standards, coding rules, and regulatory requirements Conducts focused reviews in areas identified by CDI leadership: Mortality reviews, PSI reviews, as well as other identified projects Assist with onboarding and training of new CDI team members Required Qualifications Associate’s Degree in Nursing (Bachelor’s Degree in Nursing is preferred) Three to five years of recent clinical work experience in the medical-surgical area, ICU, telemetry, and or emergency department An active US RN license is required Knowledge or experience in electronic medical records (EMR) platforms and CDI platforms For this US-based position, the base pay range is $48,131.00 - $81,225.49 per year. Individual pay is determined by role, level, location, job-related skills, experience, and relevant education or training. This job is eligible to participate in our annual bonus plan at a target of 5.00% The healthcare system is evolving continuously — with opportunities to learn, collaborate across groups, and explore new paths for your career. Our associates are given the chance to contribute, think boldly, and create meaningful work that makes a difference in the communities we serve around the world. We offer a competitive benefits package. R1 RCM Inc. (“the Company”) is dedicated to equal employment opportunity. Our employment practices — including recruitment, hiring, assignment, promotion, compensation, benefits, training, discipline, and termination — shall not be based on any protected characteristic. We are committed to providing a workplace free from harassment related to these categories. If you have a disability and require a reasonable accommodation to complete any part of the job application process, please contact us at View phone number on click.appcast.io for assistance. CA PRIVACY NOTICE: California resident job applicants can learn more about their privacy rights California Consent ( To learn more, visit: R1RCM.com Visit us on Facebook ( R1 is the leader in healthcare revenue management, helping providers achieve new levels of performance through smart orchestration. A pioneer in the industry, R1 created the first Healthcare Revenue Operating System: a modular, intelligent platform that integrates automation, AI, and human expertise to strengthen the entire revenue cycle. With more than 20 years of experience, R1 partners with 1,000 providers, including 95 of the top 100 U.S. health systems, and handles over 270 million payer transactions annually. This scale provides unmatched operational insight to help healthcare organizations unlock greater long-term value. To learn more, visit: #J-18808-Ljbffr R1 RCM