Clinical Documentation Integrity (CDI) Specialist

Clinical Documentation Integrity (CDI) Specialist

Location: Remote

Industry: Healthcare / Health Information Management / Clinical Documentation Integrity

Pay: Contract-to-Hire | Pay Rate: $45 - $50/ hour

Benefits: This position is eligible for medical, dental, vision, and 401(k).

About Our Client

Our client is a large healthcare organization expanding their internal Clinical Documentation Integrity team after transitioning CDI services back in-house from an outsourced model. They are seeking experienced CDI Specialists to support inpatient documentation integrity, reimbursement accuracy, and collaboration across clinical and coding teams in a fully remote environment.

Job Description

The Clinical Documentation Integrity (CDI) Specialist is responsible for reviewing inpatient medical records to ensure accurate and complete provider documentation that supports appropriate DRG assignment, Severity of Illness (SOI), Risk of Mortality (ROM), and overall reimbursement integrity. This role works collaboratively with physicians, coding teams, quality departments, case management, and patient financial services to improve documentation compliance and accuracy.

Key Responsibilities

• Review inpatient medical records within 24–48 hours of admission to evaluate documentation for accurate DRG assignment
• Conduct follow-up CDI reviews every 2–3 days throughout the patient stay
• Create and manage compliant physician queries for missing, conflicting, or unclear documentation
• Collaborate closely with providers, HIM Coding, Quality, Case Management, and Patient Financial Services
• Perform DRG reconciliation and review final coded DRG assignments
• Maintain knowledge of current coding guidelines, CMS regulations, AHA Coding Clinics, and CDI best practices
• Educate providers and clinical staff on documentation improvement opportunities
• Work independently in a remote setting while maintaining productivity and quality standards
• Troubleshoot basic remote technology and EMR-related issues as needed

Qualifications

Required:

• Current RN license (MD with CDIP certification will also be considered)
• 3+ years of CDI experience
• Experience reviewing inpatient acute care records
• EPIC experience
• Strong understanding of DRG assignment, SOI/ROM, and compliant query practices
• Knowledge of ICD-10 coding guidelines, anatomy & physiology, pharmacology, and disease processes
• Experience with EMR/encoder systems such as EPIC, 3M, Cerner, Meditech, Optum CAC, or Solventum
• Strong analytical, communication, and critical thinking skills

Preferred:

• CCDS, CDIP, CCS, RHIT, or related certification
• Bachelor's Degree in Nursing or Health Information Management
• CAC (Computer Assisted Coding) experience
• Experience working with remote CDI teams

Additional Details

• Start Date: 7/6
• Schedule: Monday–Friday, daytime hours
• Assignment Type: Contract-to-Hire
• Number of Openings: 20+
• Reporting To: Angela
• Assessment Requirement: Must complete the CS CDI Assessment with a target score of 90% (candidates scoring 85%+ may still be presented with review of missed questions)
• Software Used: EPIC, 3M, Meditech, Cerner, and Optum CAC

Perks

• Fully remote opportunity
• Long-term contract-to-hire potential
• Large team expansion with significant growth opportunities
• Collaborative environment working alongside Coding, Quality, and Clinical teams
• Exposure to multiple hospital systems and EMR platforms
• Consistent weekday schedule with no weekends required

Addison Group is an Equal Opportunity Employer. Addison Group provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. Addison Group complies with applicable state and local laws governing non-discrimination in employment in every location in which the company has facilities. Reasonable accommodation is available for qualified individuals with disabilities, upon request.