CLINICAL DOCUMENTATION IMPROVEMENT (CDI) NURSE II

Southwest General Health Center is a 352-bed community hospital located in Middleburg Heights, Ohio. One of the last standing community hospitals in Northeast Ohio, we partner with University Hospitals and other local community organizations to provide a full range of services to all who need us. We are certified as a Level III Trauma Center and a Primary Stroke Center, and have been serving our community for over 100 years!

Why work at SWGHC? In addition to the outstanding culture, we offer great benefits, no rotating shifts, free parking and are close to the turnpike and I71. Come join our team! #loveajobthatlovesyouback

CLINICAL DOCUMENTATION IMPROVEMENT NURSE II

POSITION SUMMARY:

The Second Level Clinical Documentation Integrity (CDI) Reviewer performs comprehensive post-discharge, pre-bill reviews of targeted patient records to ensure accurate capture of patient acuity, severity of illness, risk of mortality, and correct DRG assignment in accordance with regulatory standards. This role identifies documentation and coding opportunities, placing physician queries and collaborating with coders or the Coding Manager as needed to ensure complete and accurate medical records. The reviewer responds to CDI team requests for concurrent chart reviews of complex cases and maintains detailed summaries of identified opportunities to support team feedback and education. Working closely with CDI Leads, Educators, and fellow reviewers, this position analyzes trends, recommends criteria updates for second-level review triggers, and supports ongoing education to improve documentation quality and compliance. Principal Duties and Responsibilities

Minimum Qualifications

Education: MD or Graduate of an accredited school of nursing and current RN licensure by Ohio State Board of Nursing, Bachelor's degree preferred.

Required length of experience:

Acute care experience.

Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.

Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.

Knowledge of age-specific patient needs and the elements of disease processes and related procedures.

Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

Assertive personality traits to facilitate ongoing physician communication.

Working knowledge of inpatient admission criteria.

Ability to work independently in a time-oriented environment.