Day in the Life of a Clinical Documentation Integrity Specialist (CDIS) Nurse

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Want to know what a day in the life of a remote CDI nurse actually looks like? 

Read on to see what one California nurse does on the day-to-day, how much money she makes, and how she got into clinical documentation integrity (CDI).

1. How did you know you wanted to do CDI and how did you break into the field?

CDI nursing is a role that requires little phone time and is often a highly sought-after role for introverts. For many, it can be hard to break into CDI. 

For this California remote nurse, she says she stumbled across the job on accident. “I applied for it because I saw a position open at my hospital, but I didn’t know what it was other than it was a nursing position. There wasn’t any information on Google or with the official CDI organization, or it was behind a paywall. I was ready to try something different,” she explains.

2. What is CDI?

The responsibilities of a CDI nurse are:

  • Chart review
  • Outreach to clinical team members
  • Quality and improvement

California nurse says, “CDI was a new department at our hospital. We spoke with the director of the quality department, and the attitude was, ‘We’ll figure it out together.’ The plan was to review charts closely and look for holes in documentation that might impact our quality metrics… If there were any issues with the patient’s chart after discharge, the responsibilities were passed over to the billing and coding department.”

3. What does a typical day look like for you?

“After the learning curve, we each were assigned a floor or two in the hospital we worked at,” California nurse explains. We logged into our charting system as well as our CDI system. We would select patients that met the criteria we were looking for. Usually about 10-15 charts per day.”

“We would start going down the list and reviewing them. We read through the whole chart like we were caring for them, but we were looking for parts of the chart that needed to be validated.”

CDI nurses look into validating the following information:

  • Unsupported diagnosis codes
  • Diagnoses that haven’t been properly ruled out or ruled in
  • Specificity in charting, for example, documenting the type and level of congestive heart failure

California nurse says that they would reach out to clinical team members for additional information when needed and would give them about 24 or 48 hours until her team followed up. 

4. What type of company do you work for?

California nurse works for her hospital’s quality department in California. 

Here are some quick stats about her remote nurse job:

  • Base salary is between 100-120k
  • There are 7.2 hours of PTO accrued per pay period
  • The job is 5 days per week (40 hours)
  • There are no weekends or holidays
  • Overtime is available, but not mandatory

5. How does your company track your metrics?

California nurse says that since her department was new, they started off with 10 charts per day. “We would tally how many charts that people did per day. We all helped each other, if someone was falling behind, we would pick up the slack.” However, she says that she has seen other CDI nurses required to work 20 or more charts per day. 

Because CDI involves inquiring clinical staff to provide additional information to documentation, some other CDI companies may have a metric of a certain amount of inquiries per shift or per week.

6. Is your job flexible?

Because of the limited phone time, CDI is typically a more flexible role.

California nurse explains, “I had some flexibility because it was a remote computer-based role. My management didn’t really care when I started or ended my shift, as long as I got in my 8 hours each day.” She says they usually had the option to flex time, which means you could take off time in the middle of the day for a doctor’s appointment or other needs and make up that time before or after the shift. However, on days there was mandatory training, they were not allotted this type of flexibility.  “I always felt like I had enough PTO,” she adds.  

What about internet requirements? She said her IT department didn’t mind the location she worked from because the hospital required her to log into a VPN system. She was able to travel anywhere in the U.S., as long as she maintained a valid California RN license. The only other travel requirement was that she work in a HIPAA-compliant workspace.

7. What do you like to do in your free time?

After work, California nurse likes to sign off and take a step back from all things work-related. She mentioned enjoying going to the gym, out to dinner, and hanging out with friends and neighbors to unwind. 

8. What parts of CDI can cause burnout?

It does get tedious, she says. Although some things were exciting to review, at the end of the day, it was looking at charts for the whole shift. 

There were also some challenges when working with providers. “While we had amazing providers that understood the program, some providers made it difficult to work with them,” so they sometimes had to chase them down for documentation. 

9. What parts of CDI are exciting to you?

“It was often a really exciting time when you knew you were onto something,” California nurse explains. “Where you know that, if you asked, it would change the quality of the chart.” She also enjoyed seeing providers start to improve their documentation over time once they understood the importance of clinical documentation quality.  

At the end of the day, it was also patient care that motivated her to continue being a remote nurse. “I loved being able to see how the accuracy of the chart would end up helping the patient get appropriate and prompt care,” she shares.

Find Out if CDI Is Right for You

The life of a CDI nurse involves meticulous chart review and collaboration with healthcare providers to ensure accurate documentation. While it can be repetitive to review charts all day, the efforts of a CDI nurse do affect patient care in a positive way. The job flexibility and salary are competitive and make for a well-rounded remote nurse job role. 

Interested in seeing if CDI is for you? Check out the remote nurse job guide for CDIS nurses, or one of the other Nurse Fern guides.