Clinical Documentation Integrity Leader for AI Evaluation

Guide the evaluation of AI tools that strengthen clinical documentation accuracy, coding integrity, compliance, and revenue integrity. This remote leadership role applies deep CDI expertise to review AI-generated documentation improvement suggestions, physician queries, and coding recommendations, then provide structured feedback that helps improve healthcare AI systems. Key Responsibilities

• Lead inpatient and/or outpatient CDI programs, including concurrent and retrospective review workflows.
• Evaluate AI-generated documentation suggestions, physician queries, and coding recommendations for clinical accuracy and compliance.
• Review clinical records to ensure diagnoses, procedures, severity of illness, and risk of mortality are accurately documented.
• Develop and manage physician query processes aligned with AHIMA and ACDIS guidance.
• Monitor CDI performance indicators, including query response rates, CC/MCC capture rates, case mix index, and DRG accuracy.
• Partner with coding, compliance, and clinical teams to close documentation gaps and improve query processes.
• Educate physicians and clinical staff on documentation requirements and best practices.
• Maintain compliance with Official Coding Guidelines, CMS regulations, and payer-specific requirements.
• Annotate AI outputs and provide structured clinical feedback for AI training datasets.

• At least 5 years of CDI or clinical documentation improvement experience, including at least 2 years in a management or leadership role.
• Deep knowledge of MS-DRG methodology, CC/MCC hierarchies, and ICD-10-CM/PCS coding guidelines.
• Expertise in physician query management using AHIMA and ACDIS compliant query standards.
• A strong clinical background and ability to interpret medical records and clinical documentation.
• Proficiency with CDI platforms such as 3M, Nuance, Optum360, or equivalent, along with EHR systems.
• Exceptional written and verbal English communication skills.
• Careful, critical evaluation skills for clinical documentation and AI-generated outputs.
• Ability to work independently in a fully remote environment.

• CCDS or CDIP credential.
• Experience with HCC risk adjustment and outpatient CDI programs.
• RN, RHIA, CCS, or a similar clinical or coding credential.
• Familiarity with AI-assisted CDI tools, including Nuance DAX or 3M M*Modal, and experience evaluating AI-generated clinical content.
• Experience presenting CDI performance metrics to clinical and executive leadership.

• Remote, hourly engagement.

• $84 per hour.

• Contribute CDI expertise to advanced healthcare AI workflows focused on clinical documentation and revenue cycle management.