Clinical Documentation Integrity Leader for AI Evaluation

Lead clinical documentation integrity programs and evaluate AI-generated documentation and coding suggestions to improve documentation accuracy, coding integrity, compliance, and revenue capture. In this remote, hourly role you will manage CDI workflows for inpatient and/or outpatient settings, collaborate with coding and clinical teams, and provide structured annotations and feedback that directly inform next-generation AI systems for healthcare documentation.

• Lead clinical documentation integrity programs for inpatient and/or outpatient settings, overseeing both concurrent and retrospective review workflows.
• Evaluate AI-generated clinical documentation improvement suggestions, physician queries, and coding recommendations for clinical accuracy and compliance.
• Conduct and review clinical documentation to ensure accurate capture of diagnoses, procedures, severity of illness, and risk of mortality.
• Develop and manage physician query processes aligned with AHIMA and ACDIS guidance.
• Monitor CDI program KPIs, including query response rates, CC/MCC capture rates, case mix index, and DRG accuracy.
• Collaborate with coding, compliance, and clinical teams to address documentation gaps and improve query processes.
• Provide education to physicians and clinical staff on documentation requirements and best practices.
• Ensure compliance with Official Coding Guidelines, CMS regulations, and payer-specific requirements.
• Annotate AI outputs and provide structured clinical feedback to support AI training datasets.

• Minimum 5 years of experience in clinical documentation integrity or improvement, including at least 2 years in a manager or leadership role.
• Deep knowledge of MS-DRG methodology, CC and MCC hierarchies, and ICD-10-CM and ICD-10-PCS coding guidelines.
• Demonstrated expertise in physician query management consistent with AHIMA and ACDIS compliant query standards.
• Strong clinical background with the ability to interpret medical records and clinical documentation.
• Proficiency with CDI software platforms such as 3M, Nuance, Optum360, or equivalent, and experience using EHR systems.
• Exceptional written and verbal English communication skills, with high attention to detail for critically evaluating clinical documentation and AI outputs.
• Ability to work independently in a fully remote environment.

• CCDS or CDIP credential.
• Experience with HCC risk adjustment and outpatient CDI programs.
• Clinical or coding credentials such as RN, RHIA, or CCS.
• Familiarity with AI-assisted CDI tools, for example Nuance DAX or 3M M*Modal, and comfort evaluating AI-generated clinical content.
• Experience presenting CDI performance metrics to clinical and executive leadership.

This is a fully remote, hourly position. The role requires independent, self-directed work managing CDI activities and evaluating AI outputs in clinical documentation and coding workflows. Assignments may cover inpatient and outpatient documentation review and collaboration across coding, compliance, and clinical teams.

$84.00 per hour.

• Must be able to work remotely and independently.