Clinical Document Integrity (CDI) Specialist

Healthcare Coding And Consulting Svcs • Fort Myers, FL

5d • Remote

About The Position

Healthcare Coding & Consulting Services (HCCS) is seeking an experienced Clinical Documentation Integrity (CDI) Specialist to join their growing team. This is a fully remote, full-time opportunity supporting a nationally recognized academic healthcare organization. The ideal candidate will be an experienced CDI professional who thrives in a fast-paced Level I Trauma academic medical center environment. Every member of the team is a direct-hire W-2 employee who plays an important role in supporting high-quality healthcare documentation and patient outcomes. HCCS proudly keeps all of its coding and CDI services within the United States, allowing them to deliver exceptional quality while supporting American healthcare professionals. This role is for individuals with a passion for clinical documentation improvement, provider collaboration, and ensuring the accuracy of the medical record.

Requirements

• Active Registered Nurse (RN) license required.
• Minimum of three (3) years of recent Clinical Documentation Integrity (CDI) experience in a Level I Trauma Academic Medical Center or Teaching Hospital.
• Recent concurrent inpatient CDI experience required.
• Experience reviewing complex inpatient cases within a Level I Trauma academic healthcare environment required.
• Strong understanding of MS-DRGs, ICD-10-CM/PCS coding guidelines, severity of illness (SOI), risk of mortality (ROM), and compliant physician query practices.
• Experience collaborating directly with physicians and interdisciplinary clinical teams.
• Excellent critical thinking, analytical, and communication skills.
• Experience working within an electronic health record (Epic experience preferred, if applicable).
• Must be authorized to work in the United States.

Nice To Haves

• CCS, CIC, CDIP, and/or CCDS certification preferred, but not required.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient medical records to improve the quality and accuracy of clinical documentation.
• Identify opportunities to clarify documentation that supports accurate code assignment, severity of illness, risk of mortality, quality metrics, and reimbursement.
• Collaborate with physicians through compliant query practices to obtain complete and accurate documentation.
• Partner with inpatient coding professionals to ensure documentation supports appropriate code assignment and accurate DRG assignment.
• Monitor assigned patient populations throughout hospitalization and perform follow-up documentation reviews as needed.
• Apply current CMS regulations, ICD-10-CM/PCS coding guidelines, MS-DRG methodologies, and Coding Clinic guidance.
• Promote provider education and documentation best practices that improve documentation integrity and patient outcomes.
• Analyze documentation trends and identify opportunities for process improvement.
• Participate in multidisciplinary collaboration to support documentation integrity initiatives.
• Maintain productivity, quality, and compliance standards established by HCCS and our client partners.

Benefits

• competitive compensation
• comprehensive benefits package
• supportive leadership
• opportunities for professional growth

What This Job Offers

• Job Type: Full-time
• Career Level: Senior