CDI Specialist - Inpatient

Join a remote CDI specialist role supporting inpatient documentation review, provider communication, and accurate severity capture.

About the role

We are seeking an experienced Inpatient Clinical Documentation Integrity (CDI) Specialist for a remote opportunity supporting concurrent inpatient documentation review. This role is ideal for a detail-oriented healthcare professional who thrives in a fast-paced environment, communicates effectively with providers, and is passionate about improving documentation accuracy, severity capture, and overall medical record integrity.

Schedule

Full-time, Monday through Friday, 8-hour days (40 hours per week). Start date: 08/03/2026.

Requirements

• Minimum 3 years of CDI experience in an inpatient setting
• Strong knowledge of ICD-10 coding guidelines, CMS regulations, and DRG reimbursement methodologies
• Experience performing concurrent inpatient chart reviews
• Excellent written communication skills for provider engagement and documentation clarification
• CCDS or CDIP certification preferred

Responsibilities

• Perform initial and follow-up concurrent reviews of targeted inpatient medical records
• Review approximately 18-25 patient charts per day while maintaining quality and productivity standards
• Identify conditions that are being evaluated, monitored, or treated and ensure accurate documentation capture
• Assign principal and secondary diagnoses and identify applicable complications or comorbid conditions
• Evaluate severity of illness and risk of mortality indicators within the medical record
• Escalate documentation concerns and quality indicators as appropriate
• Complete initial reviews within 24-48 hours of admission and continue follow-up reviews every 24-48 hours as needed
• Communicate with providers and care teams through compliant written queries to clarify incomplete, conflicting, or ambiguous documentation
• Apply official coding guidelines, ethical standards, and regulatory requirements to support clinical documentation integrity
• Use designated documentation and reporting systems (Cerner and Access HIM) for CDI review, data entry, and query tracking

Benefits

• 401K with matching
• Healthcare coverage
• Dental coverage
• Vision coverage