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Clinical Documentation Integrity Specialist

HCCS - Healthcare Coding & Consulting Services

Healthcare Coding & Consulting Services (HCCS) is seeking an experienced Clinical Documentation Integrity (CDI) Specialist to support a nationally recognized academic healthcare organization. This is a fully remote, full-time, direct-hire W-2 opportunity supporting a Level I Trauma academic medical center environment.

The role focuses on improving the quality and accuracy of clinical documentation, supporting accurate code assignment, and collaborating with physicians and interdisciplinary clinical teams to strengthen documentation integrity and patient outcomes.

You will work with inpatient records, identify documentation opportunities, support compliant query practices, and help maintain quality, compliance, and productivity standards across the documentation review process.

Requirements & Qualifications
  • Active Registered Nurse (RN) license required
  • CCS, CIC, CDIP, and/or CCDS certification preferred but not required
  • Minimum of 3 years of recent Clinical Documentation Integrity (CDI) experience in a Level I Trauma Academic Medical Center or Teaching Hospital
  • Recent concurrent inpatient CDI experience required
  • Experience reviewing complex inpatient cases in a Level I Trauma academic healthcare environment required
  • Strong understanding of MS-DRGs, ICD-10-CM/PCS coding guidelines, severity of illness (SOI), risk of mortality (ROM), and compliant physician query practices
  • Experience collaborating directly with physicians and interdisciplinary clinical teams
  • Excellent critical thinking, analytical, and communication skills
  • Experience working within an electronic health record; Epic experience preferred
  • Must be authorized to work in the United States
Benefits & Perks
  • Competitive compensation
  • Comprehensive benefits package
  • Supportive leadership
  • Opportunities for professional growth
  • Long-term career stability
  • Fully remote W-2 employment
  • Direct-hire employment with a family-owned company

Location

Florida, US

Employment Type

Full-time

Experience Level

Senior

Remote work allowed

Yes

Posted

1 month ago

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