Inpatient Rehab Documentation Coordinator

About the role

The Clinical Documentation Improvement (CDI) Specialist for Inpatient Rehabilitation ensures that the medical record accurately reflects patient complexity, resources, and outcomes. Reporting to the Rehab Quality/PPS Manager, the role also serves as the RN representative on weekly Interdisciplinary Team conferences, aligning clinical status with the IRF-PAI.

Key responsibilities

• Review patient records and conduct clinical interviews to verify documentation accuracy.
• Collaborate with physicians, therapists, and case managers during IDT meetings to resolve documentation gaps.
• Ensure compliance with ICD-10-CM coding standards and Section GG functional scoring.
• Identify and correct clinical inconsistencies across multiple disciplines.
• Support reimbursement processes by linking documentation to resource utilization.

Required profile

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

Required skills

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