Clinical Document Specialist

Job Description

Job Title: CDI Specialist I (Clinical Documentation Integrity)

Location: 100% Remote (U.S. Based) - Rochester, MN 55902

Schedule: Monday – Friday | Business Hours

Contract Duration: 12 Months with possible extension

Pay Rate: $60 – $65/hr.

Key Responsibilities:

• Perform concurrent and retrospective reviews of inpatient medical records

• Ensure documentation accurately reflects severity of illness, risk of mortality, and medical necessity

• Identify documentation gaps and opportunities for improvement in clinical records

• Collaborate with physicians, coding teams, case management, and nursing staff to enhance documentation accuracy

• Facilitate appropriate documentation updates to support accurate coding and billing

• Apply knowledge of disease processes (pathophysiology), medications, and clinical indicators

• Serve as an educator and resource to providers on clinical documentation best practices

• Support quality improvement initiatives and maintain accurate reporting standards

• Maintain productivity and quality benchmarks in a production-based environment

Required Qualifications:

• High School Diploma or GED

• Minimum 2–3 years of experience as an Inpatient CDI Specialist (ICDI)

• Recent production experience within the last 12 months required

• Strong knowledge of clinical documentation, coding, and regulatory compliance

• Experience with concurrent review of medical records

Required Certifications: (One or more required)

• CDIP (Certified Documentation Improvement Practitioner) OR

• CCDS (Certified Clinical Documentation Specialist)

AND one of the following:

• RHIT / RHIA • RRT • CCS / CCS-P • MD (Medical Degree)

Preferred Skills:

• Strong knowledge of pathophysiology and pharmacology

• Experience collaborating with interdisciplinary healthcare teams

• Ability to educate providers and influence documentation practices

• Familiarity with quality metrics and clinical documentation improvement programs

Additional Notes:

• 100% Remote – Must be based in the U.S.

• Pre-screening questions required (detailed responses expected)

• Production-based role with defined performance expectations

“Pride Health offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors”.