Inpatient Rehab Documentation Coordinator

About the role

The Clinical Documentation Improvement (CDI) Specialist for Inpatient Rehabilitation ensures that medical records accurately reflect patient complexity and resource utilization. Reporting to the Rehab Quality/PPS Manager, this RN‑led position bridges clinical care, compliance, and reimbursement processes.

Key responsibilities

• Review and enhance inpatient rehab documentation to align with IRF‑PAI requirements.
• Serve as the RN representative on weekly Interdisciplinary Team (IDT) conferences, leading discussions with physicians, therapists, and case managers.
• Conduct direct clinical interviews and record reviews to verify patient status and functional scoring.
• Collaborate with coding and compliance teams to ensure accurate ICD‑10‑CM coding and Section GG functional scoring.
• Identify and resolve clinical inconsistencies across multiple disciplines.

Required profile

• Active Registered Nurse (RN) license.
• Minimum 3 years of clinical experience in an Inpatient Rehabilitation Facility (IRF) or Acute Care setting.
• Proficiency in ICD‑10‑CM coding and Section GG functional scoring.
• Strong analytical attention to detail.
• Ability to confidently lead interdisciplinary discussions.

Required skills

• ICD‑10‑CM coding
• Section GG functional scoring
• Clinical documentation improvement