Remote CDI Specialist: Clinical Documentation Integrity

Vee Healthtek, Inc.; Plano (TX); Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Medical, Dental, Vision insurance

Job summary

Vee Healthtek is seeking an experienced Clinical Documentation Integrity (CDI) Specialist to perform concurrent inpatient reviews that improve accuracy, completeness, and clinical integrity of the medical record.

The role partners with physicians, coding, and quality teams to support compliant documentation, accurate MS-DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality outcomes, and revenue integrity.

Qualifications

• Active RN license or graduate of an accredited medical program (MD, DO, MBBS, NP, PA, or equivalent).
• CDDS or CDIP certification required.
• Minimum 5 years of concurrent inpatient CDI experience in an acute care hospital.
• Strong knowledge of MS and APR-DRG reimbursement, ICD-10-CM/PCS, clinical validation, and compliant query practices.
• Experience with Epic, Cerner, Solventum 360, Iodine, SmarterDx, or similar CDI platforms.
• Excellent clinical judgment, communication, presentation, and interdisciplinary collaboration skills.

Responsibilities

• Perform concurrent inpatient documentation reviews to identify opportunities for improved documentation specificity, clinical validation, and coding accuracy.
• Conduct compliant physician queries following AHIMA/ACDIS guidance to clarify conflicting, incomplete, or ambiguous documentation.
• Support accurate ICD-10-CM/PCS coding, MS-DRG/APR-DRG assignment, POA indicators, CC/MCC capture, SOI/ROM, PSIs, HACs, and quality metrics.
• Perform clinical validation reviews for high-impact diagnoses including sepsis, acute respiratory failure, AKI, encephalopathy, malnutrition, and other complex conditions.
• Collaborate with coding, CDI, quality, and physician teams to improve documentation quality and reduce denials.
• Provide physician and CDI education based on documentation trends and audit findings.

Skills

RN license

Clinical knowledge

Communication

Interdisciplinary collaboration

Education

RN degree (Nursing) or medical degree

Tools

Epic

Cerner

Solventum 360

Iodine

SmarterDx

Job description

Vee Healthtek is seeking an experienced Clinical Documentation Integrity (CDI) Specialist to perform concurrent inpatient reviews that improve accuracy, completeness, and clinical integrity of the medical record.

The role partners with physicians, coding, and quality teams to support compliant documentation, accurate MS-DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality outcomes, and revenue integrity.