Description

Clinical Documentation Integrity (CDI) Specialist – RN (Remote)
Work Location: 100% Remote, US-based

Position Summary
We are seeking experienced and highly motivated Clinical Documentation Integrity (CDI) Specialists to join a growing healthcare team supporting one of the nation’s largest healthcare organizations. This fully remote position plays a critical role in ensuring the accuracy, completeness, and integrity of inpatient clinical documentation while supporting quality outcomes, reimbursement accuracy, and regulatory compliance.

The ideal candidate is a collaborative healthcare professional with a strong clinical background, exceptional critical thinking skills, and a passion for improving documentation quality through physician engagement and compliant query practices.

Key Responsibilities

• Perform concurrent reviews of inpatient medical records to identify documentation opportunities.
• Evaluate clinical documentation for completeness, specificity, and accuracy.
• Develop and issue compliant physician queries to clarify documentation when appropriate.
• Collaborate with providers, care teams, and other stakeholders to improve documentation quality.
• Ensure documentation accurately reflects patient severity of illness, risk of mortality, and quality metrics.
• Maintain productivity standards, including daily chart reviews and follow-up activities.
• Monitor and maintain CDI performance metrics and reporting requirements.
• Stay current with coding regulations, clinical guidelines, and documentation best practices.
• Participate in team meetings, education sessions, and process improvement initiatives.

Schedule

• Monday through Friday during standard business hours
  
  • Some options for alternative schedules available
• Weekly schedules, including flexible time and planned time off, will be coordinated with leadership.

Work Environment

• Fully remote position.
• Supportive and collaborative team culture focused on professional growth and success.
• Ideal candidates are resourceful, proactive, team-oriented professionals who enjoy solving problems and contributing to organizational goals.

Requirements

Preferred Qualifications

• Active Registered Nurse (RN) license required.
• Bachelor of Science in Nursing (BSN) preferred.
• CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Integrity Practitioner) certification preferred.
• Strong bedside nursing background required.
• Intensive Care Unit (ICU) nursing experience strongly preferred.
• Experience in a Level I Trauma Center preferred.
• Experience within an academic medical center preferred.
• Strong understanding of clinical documentation integrity principles and healthcare reimbursement methodologies.

Required Knowledge & Skills

• Ability to perform detailed clinical record reviews and identify documentation improvement opportunities.
• Strong understanding of inpatient clinical workflows and patient care documentation.
• Knowledge of compliant physician query practices.
• Excellent verbal and written communication skills.
• Strong critical thinking, clinical reasoning, and problem-solving abilities.
• Ability to work independently while collaborating effectively with remote teams.
• Strong organizational skills with the ability to manage multiple priorities.
• Goal-oriented mindset with a commitment to quality and continuous improvement.
• Positive attitude and ability to thrive in a fast-paced, team-oriented environment.

Technology Requirements

• Experience with at least 2 of the following systems: Epic, Nuance CDE One, 3M/Solventum, Cerner, Optum 360, Meditech 
• Training will be provided on internal systems and workflows.
• Candidates must demonstrate strong technical aptitude and the ability to learn new software quickly.
• Proficiency with electronic medical records and healthcare technology platforms.
• Comfortable working in a fully remote environment utilizing multiple systems simultaneously.

Equipment & Workspace Requirements

• Dedicated home office or workspace free from distractions.
• Dual screens.
• Reliable high-speed internet connection.
• Ability to effectively work with multiple applications and systems throughout the workday.
• Strong overall computer proficiency and technical skills.