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Remote Inpatient Clinical Documentation Improvement (CDI) Specialist

Remote, USA Full-time Posted 2025-05-22

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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