Clinical Documentation Integrity (CDI) Specialist

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

📋 Description

• Conduct concurrent reviews of inpatient documentation to pinpoint areas for enhancing specificity, clinical validation, and coding precision.

• Execute compliant physician queries in accordance with AHIMA/ACDIS guidelines.

• Facilitate accurate coding for ICD-10-CM/PCS, MS-DRG/APR-DRG assignments, POA indicators, CC/MCC capture, SOI/ROM, PSIs, HACs, and quality metrics.

• Carry out clinical validation reviews for significant and intricate diagnoses.

• Collaborate with coding, CDI, quality, and physician teams to elevate documentation quality and decrease denials.

• Provide education for physicians and CDI based on documentation trends and audit results.

• Oversee productivity, quality, and compliance standards.

• Engage in internal audits and continuous improvement initiatives.

• Stay updated on CMS regulations, ICD-10-CM/PCS, Coding Clinic, AHIMA, and ACDIS recommendations.

• Achieve established productivity and quality benchmarks.

• Enhance documentation accuracy and foster physician engagement.

• Aid in denial prevention and ensure compliant reimbursement.

⛳️ Requirements

• Valid RN license or graduation from an accredited medical program (MD, DO, MBBS, NP, PA, or comparable clinical background).

• CCDS or CDIP certification is mandatory.

• At least 5 years of concurrent inpatient CDI experience within an acute care hospital setting.

• In-depth knowledge of MS-DRG and APR-DRG reimbursement structures.

• Familiarity with ICD-10-CM/PCS, clinical validation, and compliant query methodologies.

• Proficiency in CDI platforms like Epic, Cerner, Solventum 360, Iodine, SmarterDx, or similar tools.

• Understanding of SOI/ROM, POA, PSIs, HACs, Vizient, Elixhauser, CMS IPPS, AHA Coding Clinic, and AHIMA/ACDIS query protocols.

• Exceptional clinical judgment, communication, presentation, and interdisciplinary collaboration abilities.

• Information regarding U.S. work eligibility is requested in the application process.

🏝️ Benefits

• Medical, dental, and vision benefits become effective on the first of the month following the date of hire.

• 401k benefits offered.

• Paid holidays provided.

• PTO/personal time available.

• Opportunities to engage in complex CDI programs.

• Professional development opportunities are available.

• Join a collaborative team that supports leading health systems in the U.S.