RN – Clinical Documentation Integrity Specialist

Carle Health

. Performs inpatient chart review to determine appropriate DRG assignment and ensure documentation supports clinical care, severity of illness, and risk of mortality .

Posted 9/21/2026full-timeRemote • Illinois • United StatesMid-LevelSenior💰 $34 - $59 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Clinical Documentation Improvement (CDI) processes, including DRG assignment, documentation compliance, and quality reporting. Proficient in utilizing EPIC and CDI software to enhance clinical outcomes and support regulatory compliance initiatives.

Highest-signal resume keywords

Licensed Registered Nurse (RN)Certified Clinical Documentation Specialist (CCDS)Certified Coding Specialist (CCS)Strong Knowledge of ICD-10 GuidelinesAbility to Use EPIC Scoring Tools

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation Improvement (CDI)DRG AssignmentCoding GuidelinesQuality MetricsDocumentation ComplianceClinical GuidelinesData ValidationPerformance ProjectsInpatient Chart ReviewComprehensive Reviews

Soft Skills

Excellent Communication SkillsAbility to Provide EducationInterpersonal Skills

Tools & Technologies

EPICCDI SoftwareElectronic Health Record (EHR) Systems

Certifications & Qualifications

Licensed Registered Nurse (RN)Certified Clinical Documentation Specialist (CCDS)Certified Coding Specialist (CCS)Registered Health Information Technician (RHIT)Registered Health Information Administrator (RHIA)

Industry Keywords

Clinical Documentation Integrity (CDI)DRG DenialsSeverity of Illness (SOI)Risk of Mortality (ROM)Quality ReportingRegulatory ComplianceClinical CareNursingHealth Information ManagementPhysician Queries

About the role

Key responsibilities & impact

Performs inpatient chart review to determine appropriate DRG assignment and ensure documentation supports clinical care, severity of illness, and risk of mortality
Coordinates with physicians, nurses, ancillary staff, and Health Information Management coders to identify and record diagnoses, procedures, and working DRGs
Performs second-level review of assigned DRGs
Provides education on CDI topics to peers, providers, and clinicians
Reviews DRG denials and provides information to the denials team for appeals
Conducts comprehensive, concurrent, and retrospective reviews of inpatient accounts
Identifies missing, unclear, or conflicting documentation affecting DRG assignment, SOI/ROM, mortality, PSI, quality metrics, and clinical outcomes
Develops and issues compliant, clinically supported physician queries
Provides guidance and training to providers and clinicians on DRG and documentation opportunities
Supports quality reporting, CDI program development, and regulatory compliance initiatives
Participates in audits, data validation, and performance projects
Uses EPIC and CDI software workflows, follows up on open queries, and reports issues to leadership
Participates in testing upgrades as an expert when needed
Attends required education sessions

Requirements

What you’ll need

Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Certified Clinical Documentation Specialist (CCDS) within 1 year - Association of Clinical Documentation Integrity Specialists (ACDIS)
Certified Coding Specialist (CCS) within 1 year - American Health Information Management Association (AHIMA)
Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA)
Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)
Licensed Physician (MD) - Illinois Department of Financial and Professional Regulation (IDFPR)
Doctorate: Medicine
College Diploma: Health Information Mgt
College Diploma: Nursing
Work experience in CDI, coding, or clinical bedside care
Strong knowledge of ICD-10 guidelines
Knowledge of electronic health record (EHR) systems
Excellent communication skills to interact with physicians
Advanced knowledge of clinical guidelines, coding updates, and CDI best practices
Ability to support documentation efforts using clinical knowledge and coding guidelines
Ability to use EPIC scoring tools and CDI software
Ability to meet production standards and established query turnaround times
Ability to maintain educational hours needed to re-certify credentials

Benefits

Comp & perks

Comprehensive benefits package
Day shift schedule, Monday-Friday
No holiday requirements
No on-call requirements
Opportunities for growth and life-long careers
Equal opportunity employment