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 use, supporting compliance and reimbursement. Reporting to the Rehab Quality/PPS Manager, the role also serves as the RN representative for weekly Interdisciplinary Team conferences.

Key responsibilities

• Ensure the medical record accurately reflects patient complexity and resources, linking clinical care, compliance, and reimbursement.
• Act as the RN representative in weekly Interdisciplinary Team conferences, conducting clinical interviews and record reviews to align patient status with the IRF‑PAI.
• Maintain accurate documentation for Section GG functional scoring.
• Utilize direct clinical interviews and record reviews to ensure alignment with IRF‑PAI requirements.

Required profile

• Active Registered Nurse (RN) license.
• Minimum 3 years of clinical experience in an Inpatient Rehabilitation Facility or acute care setting.
• Strong communication skills to lead discussions with physicians, therapists, and case managers.
• High attention to detail for identifying clinical inconsistencies across disciplines.

Required skills

• Proficiency in ICD‑10‑CM coding.
• Knowledge of Section GG functional scoring.