Clinical Documentation Integrity Specialist

Clinical Documentation Integrity (CDI) Specialist – Remote

Join Fairview as a Clinical Documentation Integrity Specialist and play a key role in ensuring accurate, complete, and compliant inpatient medical record documentation. In this fully remote position, you'll collaborate with physicians, coders, and clinical teams to review patient records, identify documentation improvement opportunities, support accurate DRG assignment, and enhance quality outcomes, regulatory compliance, and reimbursement.

This role is ideal for an experienced RN, RHIA, or RHIT professional with a strong understanding of clinical documentation, coding, and inpatient care. You'll use your analytical skills and clinical expertise to drive documentation excellence while educating providers and contributing to continuous improvement initiatives.

Why Fairview?

• Fully remote position
• Salaried role with comprehensive benefits
• As needed weekends
• Collaborative, mission-driven healthcare environment
• Opportunity to influence patient care quality and organizational outcomes

If you're passionate about clinical documentation, healthcare quality, and provider collaboration, we'd love to hear from you.

Responsibilities

• Completes a concurrent review of the medical record for assigned patients in the required timeframe.
• Performs daily case reviews and identifies diagnoses and procedures in order to assign in accurate working DRG. Performs follow-up medical record reviews to identify any additional diagnoses or procedures that may impact the DRG assignment. Confers with coders to ensure appropriate final DRG and completeness of supporting documentation.
• Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends. Confers with nursing, case management, utilization review and other clinical caregivers to explain the importance of clear and concise documentation.
• Collects and analyzes data showing the activities performed, results of interactions, improvements made in clinical documentation, and distribution of DRGs and case mix index.
• Organization Expectations, as applicable:
• Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served
• Partners with patient care giver in care/decision making.
• Communicates in a respective manner.
• Ensures a safe, secure environment.
• Individualizes plan of care to meet patient needs.
• Modifies clinical interventions based on population served.
• Provides patient education based on as assessment of learning needs of patient/care giver.
• Fulfills all organizational requirements
• Completes all required learning relevant to the role
• Complies with and maintains knowledge of all relevant laws, regulation, policies, procedures and standards.
• Fosters a culture of improvement, efficiency and innovative thinking.
• Performs other duties as assigned

Required Qualifications

Education

Associates Degree in Nursing or Health Information Management (HIM) degree or related field or equivalent experience

Experience

2 years Acute/Inpatient experience as an RN or 5 years inpatient coding experience

Licensure

One of the following is required:

Registered Nurse of MN Upon Hire

current Registered Health Information Administrator (RHIA) MN Board of Nursing or American Health Information Management Association Upon Hire

Registered Health Information Tech (RHIT) MN Board of Nursing or American Health Information Management Association Upon Hire

Skills

Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations

Knowledge of current coding and DRG classification systems

Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results

Knowledge of ICD-10-CM and DRG classification systems

Knowledge of physician and nursing unit practices

Excellent interpersonal, critical thinking and conflict management skills

Computer and data analysis skills

Excellent verbal and written communication and presentation skills

Analytical Thinking: Ability to identify issues, obtain relevant information, relate and compare data from different sources and identify alternative solutions

Attention to detail: Achieve thoroughness and accuracy when accomplishing a task

Critical Thinking: Gathers and integrates critical information, recognizing and addressing underlying assumptions of others to arrive at effective solutions

Medical Staff Relations: Builds effective partnerships with medical staff, physicians, fostering open lines of communications and establishing trust

Problem Solving: Identifies problems, determines accuracy and relevance of information, utilizes appropriate tools and staff resources along with sound judgment to generate and evaluate alternatives and to make recommendations

Written Communication: Ability to organize and express information and ideas in written form to individuals as well as groups. Constructs messages that are clear and convincing

Preferred Qualifications

Education

Bachelors Degree in Nursing for candidate's with nursing experience

Experience

5 years acute care nursing or

5 years inpatient coding experience

Licensure

Certified Clinical Documentation Specialist (CCDS) for candidate's with HIM experience American Health Information Management Association Upon Hire

Benefit Overview

Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short-term and long-term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link for additional information:

Compensation Disclaimer

The posted pay range is for a 40-hour workweek (1.0 FTE). The actual rate of pay offered within this range may depend on several factors, such as FTE, skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization values pay equity and considers the internal equity of our team when making any offer. Hiring at the maximum of the range is not typical. If your role is eligible for a sign-on bonus, the bonus program that is approved and in place at the time of offer, is what will be honored.

EEO Statement

EEO/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status