Remote Inpatient Clinical Documentation Improvement (CDI) Specialist

Santa Barbara Cottage Hospital; Maryland; Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization seeks an experienced Inpatient Clinical Documentation Integrity (CDI) Specialist to join their remote team. The role involves ensuring documentation integrity and conducting reviews of inpatient medical records while collaborating with various clinical staff. Candidates should have at least 2 years of CDI experience, relevant certifications, and strong analytical skills.

Benefits

Full Health Insurance

Flexible scheduling

Qualifications

• Minimum 2 years of inpatient CDI experience is necessary.
• CDIP or CCDS certification required.
• Experience in risk adjustment coding is preferred.

Responsibilities

• Conduct concurrent reviews of inpatient medical records.
• Prioritize reconciliation of previous CDI reviews.
• Collaborate with clinical staff to improve documentation quality.

Skills

Analytical Thinking

Attention to Detail

Communication

Education

High School diploma or GED

Tools

EPIC

3M360

Optum

Job description

Remote Inpatient Clinical Documentation Improvement (CDI) Specialist

We are seeking a detail-oriented and experiencedInpatient Clinical Documentation Integrity (CDI) Specialist Ito join our remote team. This role is essential in supporting our client’s CDI program with a special focus onreconciliation of prior reviews, weekend case coverage, and follow-up documentationacross all service lines.

The ideal candidate will have a strong background inrisk adjustment coding,concurrent inpatient CDI review, and be comfortable working independently in aproduction-driven environment. This position requires flexibility to workweekend shifts(e.g., Friday–Tuesday, Saturday–Wednesday, or Thursday–Monday) and is fully remote, with residency required in one of the approved U.S. states.

Key Responsibilities:

• Conduct concurrent reviews of inpatient medical records to ensure accurate and complete documentation.
  
• Prioritize reconciliation of previous CDI reviews and ensure continuity of documentation integrity over weekends.
  
• Query providers for clarification or additional documentation as needed.
  
• Collaborate with physicians, coders, and clinical staff to improve documentation quality and accuracy.
  
• Utilize3M360, Optum, and EPICsystems for chart review and data analysis.
  
• Monitor documentation trends and identify opportunities for improvement.
  
• Educate clinical staff on documentation best practices and compliance standards.
  
• Ensure adherence to all applicable coding guidelines, regulations, and internal policies.
  

Requirements

• Education:High School diploma or GED required.
  
• Certifications (Required):CDIP (Certified Documentation Improvement Practitioner) or CCDS (Certified Clinical Documentation Specialist).
  
• Licensure (Required, One of the following):RHIT, RHIA, RN, RRT, CCS, CCS-P, or an international/domestic medical degree (FMG/MD).
  
• Experience:
  • Minimum2 years of inpatient CDI experiencewith concurrent review responsibilities.
    
  • Recent experience (within the last 12 months) in aproduction-focused CDI role.
    
  • Risk adjustment coding experiencestrongly preferred.
    
• Technology Skills:Proficiency inEPIC, 3M360, and Optum platforms.
  
• Soft Skills:Strong analytical thinking, excellent communication, and attention to detail.
  
• Schedule:40 hours/week, 8-hour shifts, with required weekend coverage (e.g., Fri–Tues, Sat–Wed, or Thurs–Mon).
  
• Location:Fully remote. Must be US based.
  

Client offers Full Health Insurance and other benefits.