RN Clinical Documentation Integrity Specialist

Join St. Francis–Emory Healthcare, a 376-bed community-connected hospital in Columbus, GA, that blends cutting-edge care with hometown purpose. As part of the ScionHealth network, St. Francis has been recognized and awarded multiple high-performing honors by U.S. News & World Report, and received multiple disease-specific certifications from the Joint Commission, and was a rated Top Large Hospital in Georgia. St. Francis also delivers advanced heart, orthopedic, and women’s care services. At St. Francis, you will experience a culture of excellence where your work directly shapes the health of our community.

Job Summary

The Clinical Documentation Integrity (CDI) Specialist is responsible for improving the overall quality, accuracy, and completeness of clinical documentation in the medical record. Through concurrent review and collaboration with physicians, nurses, coders, and other healthcare team members, the CDI Specialist ensures that documentation reflects the true severity of illness, risk of mortality, and complexity of care. This position supports compliance, quality initiatives, and reimbursement through accurate coding and reporting.

Essential Functions

• Perform concurrent reviews of inpatient records to identify opportunities for clarification, specificity, and documentation completeness.
• Initiate and follow up on provider queries in accordance with official coding and organizational standards.
• Abstract clinical data to support coding and DRG accuracy.
• Educate physicians and clinical staff on documentation best practices and regulatory requirements.
• Review documentation for Present on Admission (POA), Hospital-Acquired Conditions (HACs), and other quality indicators.
• Collaborate with case management, quality, compliance, and HIM teams to support clinical accuracy and financial integrity.
• Analyze and report trends related to documentation improvement opportunities and query response rates.
• Maintain current knowledge of CMS regulations, IPPS, AHA Coding Clinics, and industry guidelines.
• Assist with documentation audits and performance improvement initiatives.
• Present educational sessions to providers and staff on clinical documentation topics.
• Uphold ethical, legal, and regulatory standards related to patient privacy and coding practices.

Knowledge/Skills/Abilities/Expectations

• In-depth understanding of clinical care delivery, coding systems (ICD-10, MS-DRG), and documentation regulations.
• Excellent written and verbal communication skills.
• Ability to engage physicians and interdisciplinary teams in a collaborative, educational manner.
• Proficient in EMR systems and data analytics tools.
• Strong attention to detail, organizational skills, and independent judgment.
• Ability to manage multiple tasks and meet documentation timelines.

Join St. Francis–Emory Healthcare, a 376-bed community-connected hospital in Columbus, GA, that blends cutting-edge care with hometown purpose. As part of the ScionHealth network, St. Francis has been recognized and awarded multiple high-performing honors by U.S. News & World Report, and received multiple disease-specific certifications from the Joint Commission, and was a rated Top Large Hospital in Georgia. St. Francis also delivers advanced heart, orthopedic, and women’s care services. At St. Francis, you will experience a culture of excellence where your work directly shapes the health of our community.

Job Summary

The Clinical Documentation Integrity (CDI) Specialist is responsible for improving the overall quality, accuracy, and completeness of clinical documentation in the medical record. Through concurrent review and collaboration with physicians, nurses, coders, and other healthcare team members, the CDI Specialist ensures that documentation reflects the true severity of illness, risk of mortality, and complexity of care. This position supports compliance, quality initiatives, and reimbursement through accurate coding and reporting.

Essential Functions

• Perform concurrent reviews of inpatient records to identify opportunities for clarification, specificity, and documentation completeness.
• Initiate and follow up on provider queries in accordance with official coding and organizational standards.
• Abstract clinical data to support coding and DRG accuracy.
• Educate physicians and clinical staff on documentation best practices and regulatory requirements.
• Review documentation for Present on Admission (POA), Hospital-Acquired Conditions (HACs), and other quality indicators.
• Collaborate with case management, quality, compliance, and HIM teams to support clinical accuracy and financial integrity.
• Analyze and report trends related to documentation improvement opportunities and query response rates.
• Maintain current knowledge of CMS regulations, IPPS, AHA Coding Clinics, and industry guidelines.
• Assist with documentation audits and performance improvement initiatives.
• Present educational sessions to providers and staff on clinical documentation topics.
• Uphold ethical, legal, and regulatory standards related to patient privacy and coding practices.

Knowledge/Skills/Abilities/Expectations

• In-depth understanding of clinical care delivery, coding systems (ICD-10, MS-DRG), and documentation regulations.
• Excellent written and verbal communication skills.
• Ability to engage physicians and interdisciplinary teams in a collaborative, educational manner.
• Proficient in EMR systems and data analytics tools.
• Strong attention to detail, organizational skills, and independent judgment.
• Ability to manage multiple tasks and meet documentation timelines.

Education

• Associate’s Degree in nursing, health information management or related healthcare field (Required)
• Bachelor’s Degree in nursing, health information management or related healthcare field (Preferred)
• Master’s Degree in nursing, health information management or related healthcare field (Preferred)

Licenses/Certifications

• CDIP - Clinical Documentation Improvement Professional or CCDS Upon Hire or within facility-specified time frame (Required)
• RN - Registered Nurse - State Licensure and/or Compact State Licensure in state of practice Upon Hire (Preferred)
• RHIA - Registered Health Information Administrator or RHIT Upon Hire (Preferred)

Experience

• 3+ years clinical experience (e.g., inpatient care, documentation review, or case management) (Required)
• Prior Experience with CDI, ICD-10-CM/PCS, MS-DRGs, and official coding guidelines (Preferred)

Education

• Associate’s Degree in nursing, health information management or related healthcare field (Required)
• Bachelor’s Degree in nursing, health information management or related healthcare field (Preferred)
• Master’s Degree in nursing, health information management or related healthcare field (Preferred)

Licenses/Certifications

• CDIP - Clinical Documentation Improvement Professional or CCDS Upon Hire or within facility-specified time frame (Required)
• RN - Registered Nurse - State Licensure and/or Compact State Licensure in state of practice Upon Hire (Preferred)
• RHIA - Registered Health Information Administrator or RHIT Upon Hire (Preferred)

Experience

• 3+ years clinical experience (e.g., inpatient care, documentation review, or case management) (Required)
• Prior Experience with CDI, ICD-10-CM/PCS, MS-DRGs, and official coding guidelines (Preferred)