Clinical Documentation Improvement Specialist

We are seeking an experienced Clinical Documentation Improvement Specialist (CDI Specialist) for a fully remote opportunity supporting inpatient clinical documentation integrity initiatives. The ideal candidate will have extensive CDI experience with strong knowledge of coding regulations, clinical documentation standards, and severity of illness/risk adjustment methodologies. This role focuses on improving the accuracy, completeness, and quality of medical record documentation to support compliant coding, reimbursement, and quality outcomes. Candidates must possess strong analytical and communication skills and be comfortable collaborating with physicians and multidisciplinary healthcare teams in a fast-paced remote environment.

Key Responsibilities

• Review inpatient and/or outpatient medical records concurrently and retrospectively to ensure accurate clinical documentation and coding integrity.
• Identify documentation gaps and opportunities to improve severity of illness, risk of mortality, and complexity of care capture.
• Validate that coding accurately reflects medical necessity and patient clinical status.
• Collaborate with physicians, coding teams, nursing, case management, and other healthcare professionals to clarify and improve documentation.
• Apply advanced clinical knowledge, pathophysiology, pharmacology, and coding principles to support accurate documentation practices.
• Ensure compliance with federal and state regulations, coding guidelines, payer requirements, and ethical documentation standards.
• Educate providers and healthcare staff on documentation improvement opportunities and best practices.
• Analyze medical records to support quality reporting, reimbursement accuracy, and compliant billing practices.
• Maintain productivity and quality standards while working independently in a remote environment.
• Participate in flexible scheduling, including overtime, evenings, or weekends as needed to meet business demands.

Qualifications

• Minimum of 8 years of experience as a Clinical Documentation Improvement Specialist preferred.
• Minimum of 3 years of recent inpatient CDI experience required, including concurrent medical record review.
• Must have at least 12 months of recent production-based CDI experience.
• Strong understanding of ICDI processes, clinical documentation standards, coding regulations, and reimbursement methodologies.
• Demonstrated analytical thinking, critical thinking, and problem-solving skills.
• Excellent verbal and written communication skills with the ability to effectively interact with physicians and healthcare leadership.
• Ability to work independently in a fully remote setting with minimal supervision.
• High School Diploma or GED required.
• One of the following credentials/licenses required: RHIT, RHIA, RN, RRT, CCS, CCS-P, or Medical Degree (International or Domestic).
• CDIP or CCDS certification required.
• Proficiency in reviewing complex inpatient clinical documentation and identifying coding/documentation improvement opportunities.
• Must be available to work Sunday through Thursday schedule with overtime as needed.
• English proficiency (reading, writing, and speaking) required.

Important Details:

• 30-week contract position (extensions available)
• Shift is 8-hour Sun - Thu, 40 hrs/week
• This is a fully remote position
• Pay Range: $60 - $64 per hour

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Company Description:

“Pride Health offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors”

Equal Employment Opportunity

Pride Health is an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.

Fair Chance Employment

Pride Health is a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including, the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations

We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us.