Remote Clinical Documentation Integrity (CDI) Specialist

HIMpros; United States; Remote; USD 60,000 - 90,000; Full time

Benefits offered by this job

100% Remote Work

Flexible Scheduling

Competitive Pay

PTO

Paid Holidays

Continuing Education Assistance

Paid Continuing Education Time

Training & Ongoing Support

401(k) Retirement Plan

Short-Term Disability Coverage

Company-Paid Life Insurance

Job summary

HIMpros, LLC is hiring an experienced Clinical Documentation Integrity (CDI) Specialist for a fully remote role in the United States. The CDI professional will perform concurrent and retrospective reviews to ensure accurate, complete, and compliant medical records, improving documentation quality, coding accuracy, reimbursement, and quality reporting.

Responsibilities include identifying documentation gaps, supporting provider queries, reviewing indicators for SOI and ROM, and collaborating with

Qualifications

• Minimum 2 years of CDI experience.
• Strong understanding of ICD-10-CM, MS-DRG, APR-DRG, and clinical documentation standards.
• Experience reviewing complex inpatient medical records and identifying documentation improvement opportunities.
• Proficiency with electronic health records and CDI/coding software.
• Strong analytical, communication, and critical-thinking skills.
• Reliable high-speed internet and a secure, HIPAA-compliant home office.

Responsibilities

• Perform concurrent and retrospective medical record reviews to ensure clinical documentation accuracy and compliance.
• Identify documentation gaps and opportunities for compliant provider queries.
• Review clinical indicators to support diagnosis capture, SOI, and ROM.
• Collaborate with coding professionals, providers, and healthcare teams to improve documentation integrity.
• Apply ICD-10-CM, MS-DRG, APR-DRG, CMS, and AHA Coding Clinic guidelines.
• Conduct initial, follow-up, and retrospective reviews to ensure appropriate documentation.
• Maintain productivity, accuracy, and quality standards.
• Ensure HIPAA compliance while working remotely.

Skills

CDI experience

ICD-10-CM knowledge

MS-DRG/APR-DRG knowledge

Analytical thinking

Communication skills

Critical thinking

Education

RN license and BSN

CDIP/CDDS certification

Tools

EHR software

CDI/coding software

Epic/Cerner/3M Solventum familiarity

Job description

HIMpros is hiring an experienced Clinical Documentation Integrity (CDI) Specialist !

We are seeking a detail-oriented CDI professional with experience in both concurrent and retrospective clinical documentation reviews to support accurate, complete, and compliant medical records. This fully remote opportunity allows you to use your clinical expertise to improve documentation quality, coding accuracy, reimbursement, and quality reporting.

Key Responsibilities

• Perform concurrent and retrospective medical record reviews to ensure clinical documentation accuracy, completeness, and compliance.
• Identify documentation gaps and opportunities for compliant provider queries during and after hospitalization.
• Review clinical indicators to support accurate diagnosis capture, severity of illness (SOI), and risk of mortality (ROM).
• Collaborate with coding professionals, providers, and healthcare teams to improve documentation integrity and resolve documentation discrepancies.
• Apply ICD-10-CM, MS-DRG, APR-DRG, CMS, and AHA Coding Clinic guidelines.
• Conduct initial reviews, follow-up reviews, and retrospective reviews to ensure appropriate documentation and diagnosis capture.
• Maintain established productivity, accuracy, and quality standards.
• Ensure HIPAA compliance while working remotely.

Required Qualifications

• Minimum 2 years of recent CDI experience.
• Strong understanding of ICD-10-CM, MS-DRG, APR-DRG, and clinical documentation standards.
• Experience reviewing complex inpatient medical records and identifying documentation improvement opportunities.
• Proficiency with electronic health records and CDI/coding software.
• Strong analytical, communication, and critical-thinking skills.
• Reliable high-speed internet and a secure, HIPAA-compliant home office.

Preferred Qualifications

• Active Registered Nurse (RN) license and BSN degree
• CCDS or CDIP certification.
• Experience with Epic, Cerner, 3M/Solventum, Iodine, or similar CDI platforms.
• Experience with inpatient documentation reviews, clinical validation, and quality initiatives.

At HIMpros, we value our team members and offer a supportive remote work environment with competitive benefits, including:

• 100% Remote Work
• Flexible Scheduling
• Competitive Pay
• Paid Time Off (PTO)
• Paid Holidays
• Continuing Education Assistance
• Paid Continuing Education Time
• Training & Ongoing Support
• 401(k) Retirement Plan
• Short-Term Disability Coverage
• Company-Paid Life Insurance

Why HIMpros?

HIMpros is a women-owned healthcare staffing and consulting company specializing in Health Information Management, Clinical Documentation Integrity, Medical Coding, Cancer Registry, and Trauma Registry services. We partner with healthcare organizations nationwide and provide opportunities for experienced professionals to make a meaningful impact on documentation quality and healthcare outcomes.