Clinical Documentation Improvement

Day-to-Day Responsibilities

• Review clinical documentation to ensure accuracy, completeness, and regulatory compliance
• Work directly with physicians and clinical staff to clarify documentation
• Perform Primary Diagnosis (PDX) shifting when appropriate to accurately reflect patient conditions and severity
• Identify opportunities for documentation improvement and reimbursement optimization
• Collaborate with coding and revenue cycle teams
• Support quality metrics and compliance initiatives

Must-Haves

• 3 to 5+ years of Clinical Documentation Improvement (CDI) experience
• Active Registered Nurse
• Strong understanding of PDX (Primary Diagnosis) shifting
• Experience reviewing clinical documentation for accuracy and reimbursement optimization
• Knowledge of healthcare compliance and regulatory requirements
• Strong computer skills and ability to work within EMR/documentation systems
• Excellent attention to detail and communication skills