CDI Consultant

CDI Consultant

We are seeking an experienced Clinical Documentation Improvement (CDI) Consultant to strengthen clinical documentation accuracy, coding integrity, regulatory compliance, and appropriate reimbursement across healthcare organizations. In this fully remote role, you will audit inpatient medical records, validate diagnosis and procedure codes, assess clinical documentation, and evaluate DRG assignments. You will collaborate with physicians and healthcare professionals to identify documentation gaps, develop compliant physician queries, and deliver evidence-based recommendations. Using your expertise in ICD-10-CM/PCS coding, reimbursement methodologies, and industry guidelines, you will help ensure that clinical records accurately reflect the complexity and quality of patient care. You will also contribute to quality improvement initiatives, maintain detailed audit documentation, and meet established productivity and engagement deadlines. This opportunity is ideal for a detail-oriented clinical documentation professional who thrives in an analytical, collaborative environment and wants to make a meaningful impact on healthcare quality and financial integrity.

Accountabilities:

• Audit inpatient medical records: Conduct detailed reviews of clinical documentation and claims to validate coding accuracy, clinical validity, diagnosis and procedure reporting, and compliance with established facility workflows.
• Validate coding and reimbursement: Review ICD-10-CM/PCS diagnosis and procedure codes, MS-DRG and APR-DRG assignments, discharge statuses, and reimbursement-related documentation to ensure accuracy and compliance with applicable guidelines.
• Identify documentation gaps: Analyze physician notes, medication records, laboratory results, clinical orders, and other supporting information to identify inconsistencies, missing details, and opportunities for improved documentation.
• Develop compliant physician queries: Prepare clear, concise, and clinically supported queries that address documentation gaps while adhering to established compliance standards and industry best practices.
• Collaborate with physicians: Discuss potential DRG changes, clinical validation concerns, and physician query opportunities with internal physician experts before submitting recommendations to clients.
• Prepare evidence-based audit findings: Develop detailed rationales supported by ICD-10-CM/PCS Official Coding Guidelines, AHA Coding Clinic guidance, and relevant clinical documentation standards.
• Maintain compliance and technical knowledge: Apply AHIMA and ACDIS query compliance guidance while staying current with coding updates, reimbursement trends, regulatory expectations, and client-specific requirements.
• Use documentation and workflow tools: Navigate electronic health records, coding encoders, client reporting systems, and workflow platforms to complete reviews, document findings, and support accurate reporting.
• Meet productivity and quality standards: Complete a minimum of three chart reviews per hour while maintaining high standards of accuracy, clinical judgment, and consistency.
• Maintain complete audit documentation: Prepare timely, accurate engagement workpapers and ensure all findings, supporting evidence, and recommendations are appropriately recorded.
• Support continuous improvement: Identify opportunities to enhance audit quality, streamline workflows, improve productivity, and strengthen CDI program effectiveness.
• Maintain professional and security standards: Protect confidential patient information, comply with HIPAA requirements, communicate proactively, and manage assignments and deadlines independently.

Requirements:

• Education: Bachelor's degree in Health Information Management (HIM) and/or a Registered Nurse (RN) credential. Other health-related degrees and relevant experience may be considered on a case-by-case basis.
• Required credentials: CCDS, CDIP, or CCS certification, together with an active RN license or RHIA credential.
• Clinical documentation experience: At least five years of direct experience as a Clinical Documentation Specialist or in developing a CDI program within an acute care or ambulatory healthcare setting.
• Healthcare management or consulting experience: At least five years of healthcare management experience and/or two years of CDI consulting experience.
• CDI program expertise: Strong understanding of CDI program infrastructure, workflows, reporting, performance metrics, and health information management coding processes.
• Coding and reimbursement proficiency: Demonstrated expertise in ICD-10-CM/PCS coding, MS-DRG reimbursement, and clinical documentation requirements, with a strong understanding of MS-DRG and APR-DRG methodologies.
• Clinical and coding collaboration: Experience working directly with or educating clinical documentation specialists, medical coders, and physicians on documentation accuracy, coding practices, and compliance.
• Analytical and problem-solving skills: Ability to evaluate complex medical records, assess clinical validity, identify discrepancies, interpret coding guidance, and develop well-supported audit recommendations.
• Communication skills: Excellent written and verbal communication skills, including the ability to prepare clear audit rationales, develop compliant queries, and explain findings to clinical and nonclinical stakeholders.
• Technology proficiency: Experience with electronic health record systems such as Epic, Cerner, or Meditech, along with proficiency in Microsoft Office, particularly Excel.
• Preferred leadership experience: Three or more years of supervisory or management experience, including experience supporting CDI teams, improving workflows, or overseeing program performance.
• Alternative experience consideration: Candidates with at least 10 years of related healthcare experience, preferably including three years of supervisory or management experience, may be considered in lieu of the stated educational requirements.
• Organization and accountability: Strong attention to detail, time management, and the ability to manage multiple assignments, meet engagement deadlines, and maintain accurate workpapers while meeting productivity expectations.
• Remote work readiness: Ability to work Monday through Friday during regular business hours from within the United States, using a secure, distraction-free home workspace and reliable high-speed internet.
• Confidentiality and professionalism: Commitment to HIPAA compliance, patient data protection, professional conduct, and proactive communication in a fully remote work environment.

Benefits:

• Fully remote work: Work remotely from within the United States, with company-provided computer equipment.
• Comprehensive healthcare coverage: Medical, dental, and vision insurance.
• Retirement savings: Access to a 401(k) retirement plan with a company match.
• Paid time off: Generous paid time off (PTO) and eight paid holidays.
• Professional development: Opportunities for continued learning, specialized CDI training, leadership development, and internal career advancement.
• Structured onboarding: Personalized onboarding designed to help new team members become productive and confident in their roles.
• Recognition and rewards: Employee recognition programs and performance-based rewards.
• Wellness resources: Access to employee wellness programs and discount opportunities.
• Supportive workplace culture: A collaborative, people-first environment recognized as a Great Place to Work for three consecutive years.
• Meaningful professional impact: The opportunity to improve clinical documentation quality, strengthen coding compliance, support appropriate reimbursement, and help healthcare organizations accurately represent patient care.