Clinical Documentation Specialist; CDI RN, CCDS, or CDIP

Clinical Documentation Specialist (CDI) – RN, CCDS, or CDIP

Full-Time | Remote

We are seeking an experienced Clinical Documentation Specialist (CDI) to join our team in a full-time, fully remote capacity.

The ideal candidate will have 3+ years of CDI experience, with demonstrated expertise in Behavioral Health, OB/NICU, and comprehensive chart reviews.

• Conduct concurrent and/or retrospective reviews of inpatient medical records to ensure accurate clinical documentation.
• Identify documentation gaps related to diagnoses, procedures, severity of illness, and risk of mortality.
• Issue compliant, clinically appropriate provider queries in accordance with ACDIS/AHIMA guidelines.
• Collaborate with physicians, nursing staff, and interdisciplinary teams to improve documentation quality.
• Apply ICD-10-CM/PCS coding knowledge to support accurate documentation and reporting.
• Maintain productivity and quality standards while working independently in a remote environment.
• Stay current with regulatory requirements, coding guidelines, and CDI best practices.

• Active RN license or CCDS certification.
• Minimum 3 years of CDI experience.
• Proven CDI experience in:
  • Behavioral Health
  • OB/NICU
  • Comprehensive chart reviews
• Strong clinical knowledge and critical thinking skills.
• Solid understanding of ICD-10-CM/PCS, MS-DRGs, SOI/ROM, and quality measures.
• Excellent written and verbal communication skills.
• Ability to work independently in a fully remote environment.

• Experience with multiple EHR systems.
• Prior remote CDI experience.
• RN, CCDS, or CDIP certification.

• 100% remote work environment.
• Full-time, stable employment.
• Competitive compensation.
• Full Benefits / PTO.
• Supportive and collaborative CDI team.
• Opportunities for professional growth and development.