Inpatient Rehab Documentation Coordinator

About the role

The Clinical Documentation Improvement (CDI) Specialist for Inpatient Rehabilitation ensures the medical record accurately reflects patient complexity and resources, linking clinical care, compliance, and reimbursement. Reporting to the Rehab Quality/PPS Manager, this role also serves as the Registered Nurse (RN) representative for weekly Interdisciplinary Team (IDT) conferences, using direct clinical interviews and record reviews to align patient status with the IRF‑PAI.

Key responsibilities

• Ensure the medical record accurately reflects patient complexity and resources, supporting compliance and reimbursement.
• Act as the Registered Nurse representative on weekly Interdisciplinary Team conferences, conducting clinical interviews and reviewing records to align patient status with the IRF‑PAI.
• Collaborate with physicians, therapists, and case managers to resolve documentation inconsistencies.

Required profile

• Active Registered Nurse (RN) license.
• Minimum 3 years of clinical experience in an Inpatient Rehabilitation Facility or Acute Care setting.
• Strong attention to detail and ability to identify clinical inconsistencies across disciplines.
• Confident communication skills for leading discussions with multidisciplinary teams.
• Proficiency in ICD‑10‑CM coding and Section GG functional scoring.

Required skills

• ICD‑10‑CM coding.
• Section GG functional scoring.