Remote Inpatient Clinical Documentation Improvement (CDI) Specialist
This is a remote position.
We are seeking a detail-oriented and experienced Inpatient Clinical Documentation Integrity (CDI) Specialist I to join our remote team. This role is essential in supporting our client’s CDI program with a special focus on reconciliation of prior reviews, weekend case coverage, and follow-up documentation across all service lines.
The ideal candidate will have a strong background in risk adjustment coding, concurrent inpatient CDI review, and be comfortable working independently in a production-driven environment. This position requires flexibility to work weekend shifts (e.g., Friday–Tuesday, Saturday–Wednesday, or Thursday–Monday) and is fully remote, with residency required in one of the approved U.S. states.
- Key Responsibilities:
- Conduct concurrent reviews of inpatient medical records to ensure accurate and complete documentation.
- Prioritize reconciliation of previous CDI reviews and ensure continuity of documentation integrity over weekends.
- Query providers for clarification or additional documentation as needed.
- Collaborate with physicians, coders, and clinical staff to improve documentation quality and accuracy.
- Utilize 3M360, Optum, and EPIC systems for chart review and data analysis.
- Monitor documentation trends and identify opportunities for improvement.
- Educate clinical staff on documentation best practices and compliance standards.
- Ensure adherence to all applicable coding guidelines, regulations, and internal policies.
- Requirements
- Education: High School diploma or GED required.
- Certifications (Required): CDIP (Certified Documentation Improvement Practitioner) or CCDS (Certified Clinical Documentation Specialist).
- Licensure (Required, One of the following): RHIT, RHIA, RN, RRT, CCS, CCS-P, or an international/domestic medical degree (FMG/MD).
- Experience:
- Minimum 2 years of inpatient CDI experience with concurrent review responsibilities.
- Recent experience (within the last 12 months) in a production-focused CDI role.
- Risk adjustment coding experience strongly preferred.
- Technology Skills: Proficiency in EPIC, 3M360, and Optum platforms.
- Soft Skills: Strong analytical thinking, excellent communication, and attention to detail.
- Schedule: 40 hours/week, 8-hour shifts, with required weekend coverage (e.g., Fri–Tues, Sat–Wed, or Thurs–Mon).
- Location: Fully remote. Must be US based.
Benefits Client offers Full Health Insurance and other benefits.
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