Clinical Documentation Improvement Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess and verify CDI suggestions produced by InstaNote to ensure clinical accuracy, relevance to encounters, documentation support, provider actionability, and coding/reimbursement value.

• Analyze AI-generated clinical notes to identify missing diagnoses, ensure documentation specificity, evaluate medical decision-making, confirm diagnostic support, clinical evidence, and uncover missed CDI opportunities.

• Perform routine audits of CDI features to evaluate accuracy, precision, recall, false positive and negative rates, missed opportunities, clinical relevance, specialty appropriateness, provider usability, and potential for recommendation acceptance.

• Record findings using standardized quality scorecards.

• Collaborate with Product Management and Engineering teams to deliver structured feedback on incorrect recommendations, absent clinical logic, new documentation scenarios, specialty trends, prompt enhancements, knowledge gaps, AI workflow improvements, user experience, and prioritization.

• Engage in regular AI quality review sessions.

• Create and sustain gold-standard annotated clinical cases, specialty-specific documentation examples, recommendation libraries, clinical review guidelines, evaluation datasets, and reference documentation standards.

• Review CDI recommendations across various specialties including Orthopedics, Emergency Medicine, Urgent Care, Primary Care, Cardiology, Internal Medicine, Behavioral Health, Pediatrics, and Surgical Specialties.

• Suggest specialty-specific improvements to enhance AI performance.

• Work in collaboration with Product Managers, AI Engineers, Prompt Engineers, Machine Learning Engineers, Medical Coders, Clinical Informaticists, QA Engineers, and Data Scientists.

• Convert clinical observations into product requirements and acceptance criteria.

• Generate weekly validation reports, clinical quality scorecards, analyses of false positives/negatives, missed opportunity reports, root cause analyses, product enhancement recommendations, annotated reference cases, specialty-specific feedback reports, monthly AI performance trend reports, and clinical acceptance criteria.

⛳️ Requirements

• A Bachelor's degree in Nursing, Health Information Management, Medicine, Physician Assistant Studies, or a related clinical discipline.

• Over 5 years of experience in Clinical Documentation Improvement.

• Proven experience in reviewing physician documentation for coding quality and completeness.

• In-depth knowledge of ICD-10-CM coding principles.

• Familiarity with HCC and Risk Adjustment documentation.

• Understanding of outpatient and ambulatory documentation practices.

• Experience collaborating with physicians on documentation quality initiatives.

• Exposure to AI-assisted clinical documentation solutions is preferred.

• Preferred credentials include RN / BSN, RHIA, RHIT, PA, NP, MD / DO (though not mandatory).

• Strong grasp of Clinical Documentation Improvement, ICD-10-CM, HCC, Risk Adjustment, CPT coding fundamentals, documentation specificity, medical necessity, clinical terminology, provider documentation workflows, AI-assisted documentation tools, and Electronic Health Records such as Epic, athenahealth, Cerner, and eClinicalWorks.

• Excellent clinical judgment, strong analytical capabilities, meticulous attention to detail, skill in identifying documentation gaps, conducting root cause analysis, data-driven decision-making, effective written communication, cross-functional collaboration, a mindset focused on continuous improvement, and a passion for healthcare AI and clinical innovation.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and career advancement.

• Engaging work environment with a focus on innovation and collaboration.

• Access to cutting-edge AI technology in healthcare.