Consultant - Clinical Documentation Integrity (CDI) - Healthcare

The Consultant works closely with the client’s CDI team, supporting classroom education and mentoring. The role requires ensuring the successful transfer of CDI best practices from the consulting team to the client team, facilitating accurate documentation for severity of illness (SOI) and quality in the medical record through extensive record review and interaction with physicians, health information management professionals, coding professionals, and nursing staff. Travel of 50%–75% may be required depending on project requirements and client expectations. Responsibilities Apply a strong understanding of clinical documentation and care delivery workflows, translating clinical practice into accurate documentation that supports coding, quality reporting, and case mix integrity across inpatient and outpatient/physician settings. Conduct comprehensive inpatient medical record reviews for identified payer populations upon admission and throughout hospitalization. Serve as an educational resource to client CDI teams, delivering classroom education, hands‑on teaching, and ongoing mentoring. Develop and deliver training to physicians, nurses, coding professionals, and ancillary staff on documentation best practices. Analyze clinical information to identify gaps in documentation related to SOI, POA, MS‑DRG, APR‑DRG, PSI, and quality measures. Formulate credible and compliant documentation clarifications. Work collaboratively with coding teams to ensure accuracy and completeness of documentation and diagnoses. Support clinical staff in understanding documentation needs through frequent interaction and coaching. Provide high‑quality input for client deliverables and contribute to expert reports. Provide interim CDS support as needed. Assist in developing CDI and HIM training tools, methodologies, and education materials. Qualifications Bachelor’s degree in a related discipline preferred (RN, BSN, RHIA, RHIT, HIM, or similar). 2–5 years of consulting experience with an RN or clinical background is required; RNs without consulting experience will not be considered. Experience working in an academic medical center preferred. Ideal candidates have worked in clinical operations, quality, PI, clinical transformation, or similar advisory areas. Demonstrated consulting skill set, including strong critical thinking, communication, presentation, and analytical capabilities. Enthusiasm and aptitude for teaching and mentoring, with the ability to deliver education to clinicians, coders, and internal teams. Current CCDS, CCS, or CDIP certification, or willingness and ability to obtain one, is required. RHIA, RHIT, CRC, CPC, or other coding credentials are highly preferred. Strong understanding of DRG, MS‑DRG, APR‑DRG, and HCC methodologies. Experience using EMRs such as Epic, Meditech, Cerner, 3M360, etc. Ability to translate complex clinical, documentation, and coding concepts into clear, actionable education. Strong proficiency in MS Office (Word, PowerPoint, Excel, Outlook). Excellent time‑management skills and the ability to balance multiple priorities effectively. Desire to grow within the CDI consulting space while cross‑collaborating with other IHS service lines is necessary. A self‑starter with the ability to work effectively in an ambiguous, rapidly evolving consulting environment. Salary and Benefits Salary Range: $90,000 – $135,000 per year. Job title and compensation will be determined based on qualifications and experience. Legal and Accommodation Statement Candidate must be able to submit verification of his/her legal right to work in the United States, without company sponsorship. If you need reasonable accommodation for any part of the employment process, please contact us by email at View email address on click.appcast.io. Requests for Website Accessibility and required information for online applicant tracking systems accommodation will be considered on a case‑by‑case basis. BRG is proud to be an Equal Opportunity Employer. Our hiring practices provide equal opportunity for employment without regard to race, religion, color, sex, gender, national origin, age, United States military veteran status, ancestry, sexual orientation, marital status, family structure, medical condition including genetic characteristics or information, veteran status, or mental or physical disability so long as the essential functions of the job can be performed with or without reasonable accommodation, or any other protected category under federal, state, or local law. #J-18808-Ljbffr LE001 Berkeley Research Group, LLC