Healthcare Clinical Documentation Integrity; CDI Consultant

BRG is an Equal Employment Opportunity/Affirmative Action Employer. All qualified candidates will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, disability, or protected veteran status.

Position Title: Healthcare Clinical Documentation Integrity (CDI) Consultant

Location: Remote - USA

Position Type: Full time

Requisition : JR100370

Description:

The Integrated Health Solutions (IHS) practice at Berkeley Research Group (BRG) provides end-to-end advisory support to healthcare providers, payers, investors, and other stakeholders navigating complex strategic, operational, financial, and clinical challenges. Led by seasoned healthcare executives, operators, and clinicians, IHS partners with organizations to drive sustainable performance improvement and long-term growth through strategic growth design, operating model transformation, AI and digital enablement, clinical quality and patient care optimization, and revenue strategy-helping clients build resilient, future-ready healthcare enterprises in an increasingly complex environment.

Our four core service offerings include:

• Business Transformation Advisory

• Margin & Operational Improvement

• Quality Improvement & Clinical Care

• AI & Digital Solutions

Clinical and Quality Transformation (CQT) helps providers improve care for their patients by implementing evidence-based leading practices to enhance clinical quality, operational efficiency, and care delivery.

CQT's broad-based engagements help providers transform how they deliver care through a combination of reduced complications and mortality, optimizing surgery quality and operations, improved throughput and length-of-stay reduction, improved emergency department performance, quality infrastructure enhancements, and more accurate clinical coding and documentation-helping organizations deliver better patient care and outcomes while most effectively utilizing their clinical resources and infrastructure.

CQT is currently seeking a Consultant or Managing Consultant to join our Case Mix Integrity team, with a focus on Clinical Documentation Integrity (CDI). The CDI Consultant/Managing Consultant works closely with the client's CDI team, supporting classroom education and mentoring. They are responsible for ensuring the successful transfer of CDI best practices from the consulting team to the client team. The Consultant/Managing Consultant also facilitates accurate documentation for severity of illness (SOI) and quality in the medical record, which involves extensive record review and interaction with physicians, health information management professionals, coding professionals, and nursing staff.

Job title and compensation will be determined based on qualifications and experience. We are hiring for several roles at a variety of levels. If you are a CDI professional and do not meet all of the listed criteria, we still encourage you to apply.

Flexibility for travel (50-75%) is required for this position. Travel volume is dependent on project and client needs.

Responsibilities:

• Demonstrate extensive knowledge of clinical documentation requirements and coding guidelines applicable to inpatient care and outpatient care settings.

• Review inpatient medical records for identified payer populations on admission and throughout hospitalization.

• Provide input for complete and accurate client deliverables and make valuable contributions as a team member to expert reports.

• Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.

• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI).

• Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff.

• Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient's clinical status and care.

• Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.

• Provide Interim CDS support per client need.

Requirements:

• A Bachelor's degree in a related discipline is required, preferably RN, BSN, or Health Information Management.

• A minimum of 4 years of experience as a Clinical Documentation Improvement Specialist (CDI) Specialist within a hospital setting, or as a CDI consultant, or a combination thereof, is required.

• Minimum 2 years of inpatient coding experience with ICD-10 CM/PCS preferred.

• CCDS, CCS, or CDIP Certification is required; RHIA, RHIT, CRC, or CPC certification is highly preferred.

• Possesses knowledge of DRG coding guidelines.

• Possess thorough understanding of the legal and compliance issues as they pertain to clinical documentation and coding.

• Prior experience and proficiency in…