Clinical Documentation Integrity Specialist (REMOTE)

Required Skills & Experience

-Active Registered Nurse (RN) background. -2+ years of CDI experience specifically within adult inpatient acute care. -Strong experience reviewing complex inpatient medical records -Demonstrated ability to independently identify and defend PDX shifting opportunities. -Ability to manually formulate compliant physician queries without relying solely on CDI software-generated recommendations.

-Strong knowledge of:

--Principal diagnosis selection --ICD-10-CM/PCS concepts --CC/MCC identification --Clinical indicators --CDI query practices --Inpatient documentation and coding principles -Ability to work independently while consistently meeting productivity and quality expectations. -Strong communication skills and ability to receive and implement feedback.

Nice to Have Skills & Experience

• Recent bedside nursing experience.
• ICU and/or Emergency Department experience.
• Charge Nurse experience.
• Experience working across multiple hospitals, health systems, or CDI client environments.
• Experience with 3M or comparable CDI/coding technology.

CCDS, CDIP, CCS, or similar CDI/HIM credentials are a plus.

Job Description

We are seeking an experienced Clinical Documentation Integrity (CDI) Specialist with a strong RN clinical background and adult inpatient acute-care experience. This individual will independently review complex medical records, identify documentation and principal diagnosis opportunities, formulate compliant provider queries, and ensure documentation accurately reflects the patient's clinical condition and severity of illness. The ideal candidate is a strong clinical thinker who can identify opportunities beyond software-generated recommendations and consistently meet established productivity and quality expectations.