Clinical Documentation Integrity (CDI) Specialist - Remote

Overview

Review inpatient medical records to improve clinical documentation, support accurate diagnosis and procedure capture, and help determine compliant reimbursement, severity, quality, and utilization outcomes.

What you'll do

• Conduct concurrent initial and follow-up reviews of assigned patient records.
• Identify incomplete, conflicting, or clinically unsupported documentation.
• Prepare compliant physician queries using applicable ACDIS/AHIMA guidelines.
• Identify diagnoses and procedures and assign working MS-DRGs, SOI, and ROM.
• Track query responses and enter review data into CDI and related systems.
• Collaborate with coding teams on ICD-10 coding, DRG reconciliation, and queries.
• Maintain productivity, quality benchmarks, and HIPAA compliance.

What you'll need

• Bachelor's degree, or equivalent relevant experience or an advanced degree.
• Current, active RN, MD or equivalent, RHIA, RHIT, or CCS credential and license where applicable.
• At least 2 years of acute-care inpatient hospital coding or CDI experience.
• Familiarity with encoders and DRG assignment.
• Current knowledge of official coding guidelines and Coding Clinic.
• Ability to use EHR, CDI software, coding references, and encoders.

Nice to have

• CCDS or CDIP certification.
• Strong understanding of disease processes, medical terminology, anatomy, physiology, and microbiology.
• Critical-thinking, analytical, communication, typing, and computer skills.

Details

• Remote; any location in the United States.
• Annual salary: $68,000-$113,000.
• No travel required.