Description
Clinical Documentation Specialist (CDI) – RN, CCDS, or CDIP
Full-Time | Remote
Position Summary
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.
Key Responsibilities
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
Required Qualifications
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
Preferred Qualifications
Experience with multiple EHR systems
Prior remote CDI experience
RN, CCDS, or CDIP certification
What We Offer
100% remote work environment
Full-time, stable employment
Competitive compensation
Full Benefits / PTO
Supportive and collaborative CDI team
Opportunities for professional growth and development
Requirements
Required Qualifications
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
Preferred Qualifications
Experience with multiple EHR systems
Prior remote CDI experience
RN, CCDS, or CDIP certification
