REMOTE CDI Specialist

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.
• 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 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.

Key Responsibilities

• Perform concurrent and retrospective reviews of adult inpatient medical records to ensure complete and accurate clinical documentation.
• Independently identify documentation gaps and CDI opportunities through detailed review of the clinical record.
• Evaluate and identify opportunities for Principal Diagnosis (PDX) shifting based on clinical indicators and circumstances of admission.
• Demonstrate the ability to identify opportunities beyond traditional CC/MCC capture.
• Independently formulate and submit compliant, non-leading physician/provider queries when clarification is required.
• Review clinical indicators including physician documentation, labs, imaging, medications, procedures, nursing documentation, and treatment plans.
• Collaborate with physicians, coding/HIM teams, and CDI leadership to improve documentation accuracy.
• Evaluate records for appropriate diagnosis specificity, severity of illness, risk of mortality, and accurate representation of the patient's clinical condition.
• Incorporate feedback from CDI leadership, auditors, and quality reviews.
• Adapt to varying client workflows, documentation standards, and CDI processes.
• Maintain established productivity, quality, and financial-impact expectations.