Clinical Document Integrity (CDI) Specialist

Healthcare Coding & Consulting Services (HCCS) is seeking an experienced Clinical Documentation Integrity (CDI) Specialist to join our growing team. This is a fully remote, full-time opportunity supporting a nationally recognized academic healthcare organization. We are seeking an experienced CDI professional who thrives in a fast-paced Level I Trauma academic medical center environment.

Every member of our team is a direct-hire W-2 employee who plays an important role in supporting high-quality healthcare documentation and patient outcomes. We proudly keep all of our coding and CDI services within the United States, allowing us to deliver exceptional quality while supporting American healthcare professionals.

If you have a passion for clinical documentation improvement, provider collaboration, and ensuring the accuracy of the medical record, we encourage you to apply.

Position Requirements

• Active Registered Nurse (RN) license required.
• CCS, CIC, CDIP, and/or CCDS certification preferred, but not required.
• Minimum of three (3) years of recent Clinical Documentation Integrity (CDI) experience in a Level I Trauma Academic Medical Center or Teaching Hospital.
• Recent concurrent inpatient CDI experience required.
• Experience reviewing complex inpatient cases within a Level I Trauma academic healthcare environment required.
• Strong understanding of MS-DRGs, ICD-10-CM/PCS coding guidelines, severity of illness (SOI), risk of mortality (ROM), and compliant physician query practices.
• Experience collaborating directly with physicians and interdisciplinary clinical teams.
• Excellent critical thinking, analytical, and communication skills.
• Experience working within an electronic health record (Epic experience preferred, if applicable).
• Must be authorized to work in the United States.

Key Responsibilities

• Perform concurrent and retrospective reviews of inpatient medical records to improve the quality and accuracy of clinical documentation.
• Identify opportunities to clarify documentation that supports accurate code assignment, severity of illness, risk of mortality, quality metrics, and reimbursement.
• Collaborate with physicians through compliant query practices to obtain complete and accurate documentation.
• Partner with inpatient coding professionals to ensure documentation supports appropriate code assignment and accurate DRG assignment.
• Monitor assigned patient populations throughout hospitalization and perform follow-up documentation reviews as needed.
• Apply current CMS regulations, ICD-10-CM/PCS coding guidelines, MS-DRG methodologies, and Coding Clinic guidance.
• Promote provider education and documentation best practices that improve documentation integrity and patient outcomes.
• Analyze documentation trends and identify opportunities for process improvement.
• Participate in multidisciplinary collaboration to support documentation integrity initiatives.
• Maintain productivity, quality, and compliance standards established by HCCS and our client partners.

Joining HCCS means becoming part of a family-owned company with nearly 20 years of experience serving healthcare organizations across the country. We are committed to providing long-term career stability through full-time, remote W-2 employment. Our team members enjoy competitive compensation, a comprehensive benefits package, supportive leadership, and opportunities for professional growth. You'll have the opportunity to make a meaningful impact while partnering with some of the nation's leading healthcare organizations and collaborating with experienced professionals who are committed to quality, integrity, and excellence.