Job Description
Overview
We are seeking an experienced Clinical Documentation Integrity (CDI) Specialist (RN, BSN) to support documentation improvement initiatives in a fully remote environment. This role focuses on reviewing patient records to ensure documentation accurately reflects the severity of illness and supports compliant coding, reimbursement, and quality outcomes.
- Key Responsibilities:
- Perform detailed concurrent and retrospective reviews of patient medical records to evaluate documentation quality and completeness
- Identify documentation opportunities and initiate provider queries when clarification is needed
- Partner with physicians, coding teams, and clinical staff to support accurate documentation practices
- Ensure compliance with industry guidelines and regulatory standards including CMS regulations and official coding guidance
- Maintain productivity and quality benchmarks while working within a secure remote environment
- Stay current on documentation integrity practices, coding updates, and regulatory changes
- Requirements:
- Registered Nurse (RN) with a BSN degree
- Minimum 5 years of recent experience as a CDI specialist focused on concurrent and retrospective review
- Strong understanding of coding systems (ICD-10-CM, MS-DRG, APR-DRG) and clinical documentation standards
- High-speed internet access and comfort working remotely with electronic health record systems and CDI/coding software
- Secure, HIPAA-compliant home office setup
- CDI certification (CCDS, CDIP) required
- Benefits:
- 100% Remote Work
- Flexible Scheduling
- Training & Ongoing Support
- Continuing Education Assistance
- Competitive Pay
- Medical, Dental, and Vision Insurance
- Paid Time Off
- Paid Continuing Education Time
- Paid Holidays
- 401(k) Retirement Plan
- Short-Term Disability Coverage
- Company-Paid Life Insurance
Job Types: Full-time, Contract
Pay: $50.00 - $60.00 per hour
- Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Health savings account
- Paid time off
- Vision insurance
- Experience:
- CDI: 2 years (Preferred)
- License/Certification:
- CCDS (Preferred)
- CDIP (Preferred)
- RN License (Preferred)
Work Location: Remote
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