Clinical Documentation Improvement

Clinical Documentation Improvement (CDI) Specialist – Contract

Remote

We are seeking an experienced Clinical Documentation Improvement (CDI) Specialist to support documentation accuracy, clinical validation, and quality outcomes across patient records.

This role focuses on evaluating clinical documentation, identifying gaps, and collaborating with providers to ensure accurate representation of patient conditions and care delivery.

Responsibilities

• Review clinical documentation for accuracy, completeness, and compliance
• Identify documentation gaps and support clarification through provider queries
• Perform concurrent and retrospective chart reviews
• Support accurate capture of severity of illness (SOI) and risk of mortality (ROM)
• Collaborate with providers, coders, and clinical teams to improve documentation quality

Requirements

• Background as an RN or Physician (MD/MBBS)
• Experience in Clinical Documentation Improvement (CDI)
• Strong understanding of clinical documentation and coding principles (ICD-10, DRG, etc.)
• Ability to work independently and communicate effectively with providers

Preferred

• Experience in outpatient, ambulatory, or risk adjustment (HCC) documentation
• CDIP, CCDS, CRC, or similar certification
• Experience with Epic or other EHR systems

Details

• Contract length: 6–7 months
• Remote after initial onboarding
• Standard business hours