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Remote Clinical Documentation Improvement Specialist

Remote, USA Full-time Posted 2025-05-22

Job Title: Remote Clinical Documentation Improvement Specialist (CDI II)

Location (city, state): Remote

Industry: Healthcare/Clinical Documentation

Pay: $43-$47/hour (Contract)

About Our Client:

Addison Group is hiring for a client seeking an experienced and qualified Clinical Documentation Improvement Specialist (CDI II) to join their growing team. This role emphasizes concurrent review processes and ensures comprehensive and accurate clinical documentation.

Job Description:

Key Responsibilities:

  • Conduct concurrent reviews of clinical documentation to ensure accuracy and completeness.
  • Collaborate with physicians, clinical staff, and CDI teams to address ambiguities and discrepancies in medical records.
  • Ensure documentation reflects patients' severity of illness and risk of mortality.
  • Leverage systems like EPIC and 3M to track and prioritize CDI worklists.

Qualifications:

  • Education:
    • Bachelor of Science in Nursing (BSN) highly preferred but not required.
    • Registered Nurse (RN) with an active Texas or Compact State License required.
  • Certifications:
    • Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) required.
  • Experience:
    • Minimum 4 years of acute care clinical experience in ICU or Medical-Surgical settings.
    • Minimum 4 years of CDI experience with a concurrent review focus.
  • Skills:
    • Proficiency with EPIC and 3M 360 Encompass systems (Iodine experience is a plus).
    • Strong understanding of ICD-10-CM/PCS coding guidelines and standards.
    • Adaptability, collaboration skills, and ability to effectively address clinical queries.

Additional Details:

  • Work Schedule: Monday-Friday or weekend schedules available. Initial training is Monday-Friday, 8:00 AM - 4:30 PM CST.
  • Eligibility Requirements:
    • Candidates must reside in hireable states (verify eligibility).
    • Must pass a drug screen and nicotine test (nicotine-free policy in effect).
    • Clinical knowledge will be assessed during the interview process.
  • Flexibility for weekend availability is a plus.

Perks:

  • Fully remote role.
  • Opportunity to advance in Clinical Documentation Improvement.
  • Join a supportive and collaborative work environment.

Apply today with your updated resume and credentials, including license and certification details, to take the next step in your CDI career!

Addison Group is an Equal Opportunity Employer. Addison Group provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. Addison Group complies with applicable state and local laws governing non-discrimination in employment in every location in which the company has facilities. Reasonable accommodation is available for qualified individuals with disabilities, upon request.

IND 004-007

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