CDI Specialist

Clinical Documentation SpecialistRequired Skills & ExperienceEducation: RN, graduate of accredited nursing program and Bachelor of Science in Nursing required within 5 years of hire.Experience: A minimum of three years of experience as a Clinical Documentation Specialist is required. Clinical experience in multiple areas, particularly in the ICU, is preferred.Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia.Epic and 3M experienceJob DescriptionIn this role, you will leverage both your clinical background and CDI expertise to evaluate complex inpatient records and ensure documentation accurately reflects patient acuity and care delivery. This is a highly collaborative yet independent position, requiring strong clinical judgment without direct patient interaction.On a Typical Day, You Will:-Review inpatient medical records for accuracy, completeness, and compliance-Identify documentation gaps, inconsistencies, and opportunities for clarification-Issue physician queries to resolve unclear or incomplete documentation-Partner with interdisciplinary teams, including: Physicians and advanced practice providers Coding professionals Quality teams and service lines Specialty teams such as wound care and nutrition-Support accurate coding prior to discharge-Ensures the accuracy and completeness of clinical information, which is used for measuring and reporting physician and hospital outcomes-Provide education to providers to strengthen documentation practices-Manage a steady caseload >/= 15 new cases per day, along with follow-ups and re-reviews