Clinical Documentation Integrity Specialist

Medasource; United States; À distance; USD 69 000 - 83 000; Plein temps

Résumé du poste

Medasource is hiring an experienced CDI Specialist to support a large, multi-state health system on a fully remote, contract-to-hire engagement. You will review inpatient records and collaborate with providers to ensure documentation reflects severity of illness, risk of mortality, and care complexity.

RN license is not required. CCDS or CDIP certification preferred; candidates from HIM or coding backgrounds will be considered.

Qualifications

• 5+ years of acute care inpatient CDI experience, or 5+ years as inpatient coding auditor in a large health system.
• CCDS or CDIP certification (may be completed within first year).
• Experience with PSI exclusions and quality reviews.
• Ability to write compliant provider queries.
• Strong knowledge of disease processes and ICD-10-CM/PCS.
• Ability to apply Official Coding Guidelines and AHA Coding Clinic guidance.
• Experience with EMR/encoder systems such as Epic, Cerner, Meditech, Optum eCAC, Solventum.
• Work independently in a remote setting; strong communication skills.

Responsabilités

• Complete initial record reviews within 24–48 hours of admission and identify diagnoses and procedures for DRG.
• Conduct follow-up reviews every 2–3 days to support the working DRG.
• Write compliant provider queries per AHIMA/ACDIS guidelines.
• Follow up daily on open queries to keep responses on track.
• Review final coded DRGs and complete DRG reconciliation.
• Partner with HIM coding, quality, case management, and patient financial services.
• Educate providers on documentation best practices.
• Stay current on Official Coding Guidelines, AHA Coding Clinic, CMS directives.

Connaissances

CDI experience

Inpatient coding audit

Remote work

Communication skills

Query writing

DRG knowledge

Strong knowledge of ICD-10-CM/PCS

EMIR systems experience

Formation

CCDS or CDIP certification

Bachelor’s degree in HIM/Nursing/related field

RHIT/RHIA (nice-to-have)

Outils

Epic

Cerner

Meditech

Optum eCAC

Solventum

Description du poste

Clinical Documentation Integrity (CDI) Specialist – Remote

Medasource | Contract-to-Hire | W2 Only

Pay: $50–$60/hr

Start Date: 10/26, 11/2, or 11/9

Contract Length: 6–12 months, with strong potential for conversion

Hours: Full-time 40 hours each week

Openings: 12

Job Description:

Medasource is hiring experienced CDI Specialists to support a large, multi-state health system on a fully remote, contract-to-hire engagement. In this role, you’ll review inpatient medical records and work with providers to make sure documentation accurately reflects each patient’s severity of illness, risk of mortality, and complexity of care.

An RN license is not required. If you have a strong inpatient CDI or inpatient coding audit background and a CCDS or CDIP certification, we want to hear from you, including candidates who came up through HIM or coding.

What You’ll Do

• Complete initial record reviews within 24–48 hours of admission, identifying the principal diagnosis, secondary diagnoses, and procedures for accurate DRG assignment
• Conduct follow-up reviews every 2–3 days to support the working DRG
• Write compliant provider queries for missing, unclear, or conflicting documentation, following AHIMA/ACDIS guidelines
• Follow up daily on open queries to keep provider responses on track
• Review final coded DRGs and complete the DRG reconciliation process
• Partner with HIM coding, quality, case management, and patient financial services teams
• Educate providers and care teams on documentation best practices
• Stay current on Official Coding Guidelines, AHA Coding Clinic, and CMS directives\

What You’ll Bring

• 5+ years of acute care inpatient CDI experience, or 5+ years as an inpatient coding auditor, in a large hospital or health system
• CCDS or CDIP certification (candidates without one may be considered if they complete it within their first year)
• Experience with PSI exclusions and other quality reviews
• Ability to write compliant provider queries
• Strong knowledge of disease processes, anatomy and physiology, pharmacology, and ICD-10-CM/PCS
• Ability to apply Official Coding Guidelines and AHA Coding Clinic advice
• Experience with EMR and encoder systems such as Epic, Cerner, Meditech, Optum eCAC, and Solventum
• Ability to work independently in a remote setting and resolve basic technical issues
• Strong communication skills, including presenting to groups

Nice to Have

• CCS, RHIT, or RHIA certification
• Computer-Assisted Coding (CAC) experience
• Bachelor’s degree in HIM, Nursing, or a related field

Why This Role

• Fully remote, with equipment provided by Medasource
• 4–8 week training period to get you up to speed
• Long-term contract with strong potential for conversion to a permanent role

Process:

Qualified candidates will complete a CDI skills assessment. Strong scorers with 5+ years of recent inpatient CDI experience may move straight to an offer.

Requirements:

Background check, drug screen, and vaccinations are required.

Medasource is an equal opportunity employer that does not discriminate on the basis of actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth, lactation and related medical conditions), gender identity or gender expression, sexual orientation, marital status, military service and veteran status, physical or mental disability, protected medical condition as defined by applicable state or local law, genetic information, or any other characteristic protected by applicable federal, state, or local laws and Ordinances