CDI Consultant

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a CDI Consultant based in the United States.

We are seeking an experienced Clinical Documentation Improvement (CDI) Consultant to strengthen clinical documentation accuracy, coding integrity, regulatory compliance, and appropriate reimbursement across healthcare organizations. In this fully remote role, you will audit inpatient medical records, validate diagnosis and procedure codes, assess clinical documentation, and evaluate DRG assignments. You will collaborate with physicians and healthcare professionals to identify documentation gaps, develop compliant physician queries, and deliver evidence‑based recommendations.

Using your expertise in ICD‑10‑CM/PCS coding, reimbursement methodologies, and industry guidelines, you will help ensure that clinical records accurately reflect the complexity and quality of patient care. You will also contribute to quality improvement initiatives, maintain detailed audit documentation, and meet established productivity and engagement deadlines. This opportunity is ideal for a detail‑oriented clinical documentation professional who thrives in an analytical, collaborative environment and wants to make a meaningful impact on healthcare quality and financial integrity.

• Audit inpatient medical records: Conduct detailed reviews of clinical documentation and claims to validate coding accuracy, clinical validity, diagnosis and procedure reporting, and compliance with established facility workflows.

• Validate coding and reimbursement: Review ICD‑10‑CM/PCS diagnosis and procedure codes, MS‑DRG and APR‑DRG assignments, discharge statuses, and reimbursement‑related documentation to ensure accuracy and compliance with applicable guidelines.

• Identify documentation gaps: Analyze physician notes, medication records, laboratory results, clinical orders, and other supporting information to identify inconsistencies, missing details, and opportunities for improved documentation.

• Develop compliant physician queries: Prepare clear, concise, and clinically supported queries that address documentation gaps while adhering to established compliance standards and industry best practices.

• Collaborate with physicians: Discuss potential DRG changes, clinical validation concerns, and physician query opportunities with internal physician experts before submitting recommendations to clients.

• Prepare evidence‑based audit findings: Develop detailed rationales supported by ICD‑10‑CM/PCS Official Coding Guidelines, AHA Coding Clinic guidance, and relevant clinical documentation standards.

• Maintain compliance and technical knowledge: Apply AHIMA and ACDIS query compliance guidance while staying current with coding updates, reimbursement trends, regulatory expectations, and client‑specific requirements.

• Use documentation and workflow tools: Navigate electronic health records, coding encoders, client reporting systems, and workflow platforms to complete reviews, document findings, and support accurate reporting.

• Meet productivity and quality standards: Complete a minimum of three chart reviews per hour while maintaining high standards of accuracy, clinical judgment, and consistency.

• Maintain complete audit documentation: Prepare timely, accurate engagement work papers and ensure all findings, supporting evidence, and recommendations are appropriately recorded.

• Support continuous improvement: Identify opportunities to enhance audit quality, streamline workflows, improve productivity, and strengthen CDI program effectiveness.

• Maintain professional and security standards: Protect confidential patient information, comply with HIPAA requirements, communicate…