Job Description

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Clinical Documentation Integrity (CDI) Specialist based in United States. This remote role focuses on improving the accuracy, completeness, and clinical integrity of inpatient medical documentation. You will review health records to identify opportunities to clarify diagnoses, procedures, severity, outcomes, and quality indicators. Working closely with physicians, healthcare professionals, and coding teams, you will help ensure documentation accurately reflects the care provided. The position combines clinical knowledge, coding expertise, analytical thinking, and effective physician communication. You will manage concurrent reviews, compliant queries, working DRGs, and documentation-related workflows. Success requires strong attention to detail, sound clinical judgment, and the ability to work independently while maintaining productivity and quality standards. Accountabilities: - Conduct comprehensive initial and follow-up concurrent reviews of inpatient medical records according to established CDI priorities, timelines, and review frequencies. - Identify incomplete, conflicting, or clinically unclear documentation and determine appropriate opportunities for clarification or diagnosis validation. - Apply clinical validation principles and current ACDIS/AHIMA compliant query guidelines when preparing written queries for treating physicians. - Develop compliant queries using approved templates and ensure that relevant, patient-specific clinical indicators are accurately documented. - Identify principal and secondary diagnoses and significant procedures to establish and update the appropriate working MS-DRG. - Monitor documentation throughout concurrent reviews and update working DRGs and expected length-of-stay considerations as appropriate. - Apply knowledge of Patient Safety Indicators, Hospital-Acquired Conditions, Severity of Illness, Risk of Mortality, and present-on-admission status. - Track physician responses to queries and ensure all relevant outcomes and documentation are accurately captured in the appropriate systems.

- Maintain productivity and quality benchmarks while effectively managing daily CDI worklists and priorities. - Enter required information into CDI applications and related systems to support final MS-DRG, SOI, and ROM determinations. - Use electronic coding references, Official Coding Guidelines, and Coding Clinic resources to support accurate coding and working DRG assignments. - Collaborate with coding teams on ICD-10 coding questions, MS-DRG assignments, concurrent and retrospective queries, and DRG reconciliation. - Participate in DRG reconciliation activities in a timely, thorough, and collaborative manner. - Contribute to departmental committees, hospital task forces, service-line meetings, and other assigned initiatives. - Promote a positive, collaborative working environment while maintaining compliance with HIPAA requirements and applicable codes of conduct. Requirements - Bachelor’s degree preferred; relevant professional experience or an advanced degree may substitute for formal education. - Current and active credentials as an RN, MD or equivalent, RHIA, RHIT, or CCS . - At least 2 years of acute-care inpatient hospital coding or CDI experience . - Familiarity with encoder systems and MS-DRG assignment. - Current working knowledge of official coding guidelines and Coding Clinic resources. - Strong clinical understanding of disease processes and the ability to apply clinical indicators appropriately to documentation reviews. - Strong knowledge of medical terminology, anatomy, physiology, microbiology, and related clinical concepts. - Demonstrated critical-thinking, analytical, and problem-solving abilities. - Experience working with EHR systems, CDI software, coding applications, and electronic encoders.

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