Clinical Documentation Improvement Specialist

Job Overview

R1 is a leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems, and medical groups. As a Clinical Documentation Improvement (CDI) Specialist, you will apply clinical and coding knowledge to conduct concurrent and retrospective reviews of inpatient medical records.

• Conduct simultaneous and retrospective reviews of inpatient medical records, evaluating the documentation of clinical services.
• Identify opportunities to enhance medical record documentation quality, including focused reviews in Mortality reviews, PSI reviews, and other projects identified by CDI leadership.
• Collect appropriate physician documentation for clinical conditions or procedures to support accurate severity of illness, expected risk of mortality, and complexity of care.
• Participate in initiatives to improve documentation, including formal and informal education plans for providers and the CDI team.
• Initiate physician interaction when documentation is ambiguous, missing, or conflicting via the physician query process or rounding, to request additional documentation necessary for accurate coding and compliance.
• Educate physicians and staff on documentation requirements, coding guidelines, and reimbursement policies.
• Apply hospital coding code sets, policies, procedures, Federal and State guidelines, and Coding Clinic guidelines to assign the appropriate DRG and ensure codes are reported at the highest specificity.
• Collaborate with coders, auditors, quality improvement teams, and other stakeholders to resolve documentation issues and improve coding accuracy.
• Stay current with developments in clinical documentation standards, coding rules, and regulatory requirements.
• Assist with onboarding and training of new CDI team members.

• Associate’s Degree in Nursing (Bachelor’s Degree preferred).
• Three to five years of recent clinical work experience in medical-surgical, ICU, telemetry, or emergency department settings.
• Active U.S. RN license required.
• Experience with electronic medical record (EMR) platforms and CDI platforms.
• High proficiency in CDI practices, coding, and documentation requirements related to quality outcomes and reimbursement.
• Self-motivated and capable of staying current with CMS rules, regulations, and updates.
• Flexibility to work in a fast-paced and dynamic environment.
• Strong interpersonal skills, initiative, and the ability to work independently with minimal supervision.
• Basic computer skills including Word, Excel, PowerPoint, and Outlook/email.
• Strong judgment, critical thinking, and independent decision-making abilities.

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 position is eligible for an annual bonus plan at a target of 5.00%.

Employees receive a competitive benefits package, which may include health, dental, vision, retirement, and other standard benefits.

R1 RCM Inc. (“the Company”) is dedicated to the fundamentals of equal employment opportunity. The Company’s employment practices—including recruitment, hiring, assignment, promotion, compensation, benefits, training, discipline, and termination—shall not be based on any person’s age, color, national origin, citizenship status, disability, medical condition, race, religion, creed, gender, sex, sexual orientation, gender identity/ expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state, or local law.

The Company is committed to providing a workplace free from harassment based on any of the foregoing protected categories. If you have a disability and require reasonable accommodation for the application process, please contact  for assistance.