Consultant – Clinical Documentation Integrity, Healthcare
Posted 2026-05-06
Remote, USA
Full-time
Immediate Start
- Job Description:
- Apply strong understanding of clinical documentation and care delivery workflows.
- Conduct comprehensive inpatient medical record reviews for identified payer populations.
- Serve as an educational resource to client CDI teams.
- Develop and deliver training to physicians, nurses, coding professionals, and ancillary staff on documentation best practices.
- Analyze clinical information to identify gaps in documentation related to SOI, POA, MS-DRG, APR-DRG, PSI, and quality measures.
- Work collaboratively with coding teams to ensure accuracy and completeness of documentation and diagnoses.
- Requirements:
- Bachelor’s degree in a related discipline preferred (RN, BSN, RHIA, RHIT, HIM, or similar).
- 2-5 years of consulting experience with an RN or clinical background is required.
- RNs without consulting experience will not be considered.
- Experience working in an academic medical center preferred.
- Current CCDS, CCS, or CDIP certification, or willingness and ability to obtain one, is required.
- Strong understanding of DRG, MS‑DRG, APR‑DRG, and HCC methodologies.
- Experience using EMRs such as Epic, Meditech, Cerner, 3M 360, etc.
- Strong proficiency in MS Office (Word, PowerPoint, Excel, Outlook).
- Benefits:
- Health insurance
- 401(k) matching
- Remote work options