Inpatient Rehab Documentation Coordinator

About the role

The Clinical Documentation Improvement (CDI) Specialist for Inpatient Rehabilitation ensures that each patient’s medical record accurately reflects the complexity of care delivered and the resources utilized. Reporting to the Rehab Quality/PPS Manager, the role also acts as the RN representative on weekly Interdisciplinary Team meetings, aligning clinical information with the IRF‑PAI.

Key responsibilities

• Review and validate inpatient rehabilitation records to ensure compliance with coding and reimbursement standards.
• Conduct direct clinical interviews and collaborate with physicians, therapists, and case managers during IDT conferences.
• Identify and resolve inconsistencies across disciplines, ensuring accurate documentation of patient status.
• Maintain up‑to‑date knowledge of ICD‑10‑CM codes and Section GG functional scoring.
• Provide feedback and education to clinical staff on documentation best practices.

Required profile

• Active Registered Nurse (RN) license.
• Minimum 3 years of clinical experience in an Inpatient Rehab Facility (IRF) or Acute Care setting.
• Strong analytical mindset with high attention to detail.
• Confidence to lead discussions among multidisciplinary teams.

Required skills

• Proficiency in ICD‑10‑CM coding.
• Experience with Section GG functional scoring.