CDI Specialist — Elevate Documentation & Care Quality

NurseRemotely; United States; Remote; USD 105,000 - 150,000; Full time

Job summary

NurseRemotely in the United States is seeking a Clinical Documentation Integrity (CDI) Specialist to conduct concurrent reviews of inpatient records, ensuring accurate and compliant documentation that reflects patient acuity and supports coding and quality outcomes.

You will identify missing diagnoses, initiate physician queries, educate providers, and collaborate with Coding, HIM, and other teams in a fast-paced environment while maintaining strong communication with physicians and internal

Qualifications

• Current RN, PA, or NP license in NYS.
• Minimum of 3 years of clinical experience in an acute care setting (e.g., inpatient bedside nursing, case management).
• Strong clinical knowledge, including pathology and physiology.
• Excellent written and verbal communication skills.
• Strong critical thinking skills.
• Working knowledge of inpatient admission criteria.
• Ability to work independently and manage time effectively in a deadline-driven environment.

Responsibilities

• Conduct initial and follow-up concurrent reviews of inpatient medical records to identify opportunities for improved documentation.
• Analyze clinical indicators to identify diagnoses or conditions not yet documented in the record.
• Determine and validate the appropriate principal and secondary diagnoses to accurately reflect patient acuity.
• Initiate and follow up on physician queries (written and verbal) to obtain complete and accurate documentation.
• Build and maintain strong working relationships with physicians to facilitate effective communication and documentation improvement.
• Provide education to physicians on documentation best practices, both in group settings and one-on-one.
• Document review findings and key information within workflow and tracking tools.
• Collaborate with Coding, HIM, and other departments to ensure alignment on documentation and level of care.
• Utilize data and feedback from leadership to prioritize focus areas and improve performance.
• Manage daily responsibilities effectively, maintaining flexibility in a fast-paced environment.

Skills

RN/PA/NP license NYS

Clinical experience 3+ years

Clinical knowledge

Communication skills

Critical thinking

Inpatient admission criteria

Job description

NurseRemotely in the United States is seeking a Clinical Documentation Integrity (CDI) Specialist to conduct concurrent reviews of inpatient records, ensuring accurate and compliant documentation that reflects patient acuity and supports coding and quality outcomes.

You will identify missing diagnoses, initiate physician queries, educate providers, and collaborate with Coding, HIM, and other teams in a fast-paced environment while maintaining strong communication with physicians and internal