Clinical Documentation Specialist (CDI)

Job Description

Location: Remote (US-based)

We are seeking a Clinical Documentation Specialist (CDI) to support concurrent inpatient documentation review across a multi-facility acute care health system. This role is responsible for evaluating clinical documentation quality, identifying documentation opportunities, supporting DRG integrity, and collaborating with providers and coding teams to ensure accurate representation of patient severity and reimbursement.

This position is ideal for a clinically strong CDI professional who thrives in a remote environment, understands the intersection of documentation integrity and patient care, and is confident navigating complex DRG assignments across multiple service lines.

Responsibilities:

• Conduct concurrent inpatient chart reviews across assigned patient accounts and prioritize cases based on clinical complexity and DRG impact
• Analyze medical records to identify documentation gaps, severity indicators, and opportunities for ICD-10 specificity improvement
• Compose compliant physician queries in accordance with ACDIS and AHIMA guidelines
• Apply MS-DRG and APR-DRG methodologies to evaluate working DRG assignments and reimbursement impact
• Collaborate with inpatient coders to validate DRG assignments and resolve documentation discrepancies
• Maintain detailed documentation of chart reviews, physician queries, and CDI activities within CDI platforms
• Communicate with physicians and clinical staff to resolve open documentation opportunities prior to discharge
• Partner with coding teams on DRG validation, reconciliation, and complex inpatient cases
• Monitor productivity metrics including review volume, query rates, and case mix index (CMI) impact
• Identify trends and escalate documentation concerns or workflow barriers to leadership
• Support documentation quality initiatives and ongoing CDI process improvement efforts
• Maintain compliance with organizational, regulatory, and coding documentation standards

Qualifications:

• Active RN license required; BSN preferred. RHIA, RHIT, or physician background also considered
• Minimum of 2 years of inpatient CDI experience required
• Minimum of 3 years of inpatient clinical documentation, coding, or related acute care experience preferred
• CCDS or CDIP certification required at hire or within designated timeframe
• Advanced understanding of MS-DRG and APR-DRG methodology required
• Strong knowledge of ICD-10-CM and ICD-10-PCS coding guidelines and sequencing rules
• Experience using CDI platforms such as 3M, Epic, Nuance, Optum, or similar systems
• Strong analytical, communication, and physician collaboration skills
• Ability to work independently within a remote environment while maintaining productivity expectations

Schedule

• Full-time, remote position
• Monday through Friday standard business hours
• Eastern time zone availability required

Salary

The salary range for this position is approximately $88,000 – $125,000 annually ($42.31 – $60.10 per hour), based on experience and qualifications.

Interview Process:

• Selected candidates will participate in a multi-step interview process, including an initial screening with TalentLNX followed by interviews with department leadership.

Equal Opportunity Employer: TalentLNX is committed to equal employment opportunity and a diverse, inclusive workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.