Job Description

Clinical Documentation Integrity (CDI) Specialist

Immediate need for a talented Clinical Documentation Integrity (CDI) Specialist. This is a 06+months contract opportunity with long-term potential and is located in U.S (Remote).

Key Responsibilities:

• Perform concurrent and retrospective reviews of inpatient medical records to ensure complete and accurate clinical documentation.
• Identify opportunities to improve documentation related to severity of illness (SOI), risk of mortality (ROM), quality indicators, and reimbursement.
• Develop and issue compliant physician queries following AHIMA, ACDIS, and organizational guidelines.
• Collaborate with physicians, coding professionals, case management, utilization review, and quality teams to improve documentation accuracy.
• Validate principal diagnoses, secondary diagnoses, CC/MCC capture, MS-DRG assignments, and clinical indicators.
• Support denial prevention and appeals by providing clinical validation and documentation support.
• Monitor documentation trends and identify opportunities for physician education.
• Participate in interdisciplinary rounds and CDI team meetings.
• Analyze clinical documentation data and provide recommendations for process improvement.
• Assist in the development and delivery of provider education programs related to documentation best practices.
• Maintain productivity and quality standards while managing a high-volume review workload.
• Ensure compliance with CMS regulations, Coding Clinic guidance, and organizational policies.

Key Requirements and Technology Experience:

• Associate Degree in Nursing (ADN), BSN, MSN, Doctor of Medicine (MD), or Foreign Medical Graduate.
• Active RN License OR Medical Degree (Foreign Medical Graduates with post-graduate clinical patient care experience will be considered).
• Minimum 4 years of clinical nursing or physician experience in an acute care setting.
• Minimum 2 years of Clinical Documentation Integrity (CDI) experience.
• Experience reviewing inpatient medical records and assigning DRGs.
• Strong knowledge of:
• ICD-10-CM
• MS-DRGs
• Clinical validation
• Severity of Illness (SOI)
• Risk of Mortality (ROM)
• Documentation improvement methodologies
• Experience writing compliant physician queries.
• Strong analytical, communication, and critical thinking skills.
• Ability to work independently in a fully remote environment.
• BSN, MSN, MD, or higher clinical degree.
• CCDS, CDIP, CCS, CPC, RHIA, or RHIT certification.
• Experience with 3M CDI and coding applications.
• ICU, Critical Care, Emergency Department, Hospitalist, Case Management, Utilization Review, or CDI experience.

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