Job Details

Senior Clinical Documentation Specialist (CDI)

Remote Role (Must reside in one of the following states for FTE conversion: AL, AZ, AR, FL, GA, ID, IN, IA, KS, LA, MS, MO, MT, NC, OH, OK, SC, SD, TN, TX, UT, VA, WY)

Contract-to-Hire (3 Month Contract-to-Hire)

Compensation: $35-50 per hour (Pay range is a general guideline; final offer will consider experience, education, skills, and internal equity)

ABOUT THE ROLE

Our client is seeking an experienced Senior Clinical Documentation Specialist (CDI) for a 100% remote, contract-to-hire position. This role is focused on supporting documentation integrity, quality improvement, and provider collaboration within a complex acute care environment. As a Senior CDI Specialist, you will be responsible for improving the overall quality and completeness of provider documentation to accurately reflect severity of illness, risk of mortality, complexity of care, and condition categories. You will serve as a subject matter expert, assist with onboarding and training, participate in special projects, and collaborate closely with physicians, HIM coding teams, nursing staff, and operational leadership. This position offers flexible scheduling within EST business hours, a collaborative and accountable remote work environment, and strong long-term conversion potential for candidates residing in approved states.

WHAT YOU’LL DO

• Review medical records for documentation quality, completeness, and accuracy
• Identify gaps, conflicting documentation, and unspecified diagnoses
• Develop compliant provider queries to improve documentation specificity
• Ensure documentation accurately reflects severity of illness and risk of mortality
• Collaborate directly with physicians and clinical staff through meetings, rounding, Zoom calls, phone calls, and email
• Assist with provider education related to documentation improvement practices
• Utilize clinical judgment, NLP tools, and CDI software platforms to support documentation review
• Partner with HIM coding teams to support accurate reimbursement and reporting outcomes
• Support onboarding and mentoring of junior CDI team members
• Participate in operational and leadership-driven CDI initiatives and special projects

WHAT YOU BRING

• Associate’s Degree in Nursing, Health Information Management (HIM), or a related healthcare field
• Minimum 6 years of acute care Clinical Documentation Improvement (CDI) experience
• Strong understanding of ICD-10-CM/ICD-10-PCS coding, Medicare/Medicaid/commercial payer guidelines, and clinical documentation improvement practices
• Proven ability to independently develop compliant provider queries and collaborate directly with providers
• Experience with at least two of the following: Optum 360 eCAC, Cerner EHR, Vizient
• Strong inpatient CDI background
• Strong written and verbal communication skills
• Critical thinking and problem-solving ability
• Ability to work independently in a remote environment
• Experience mentoring or training other CDI staff (preferred)
• One of the following certifications preferred: CCDS, CDIP, CDEI, or active RN license
• Oncology experience, Vizient experience, or Cerner experience (preferred)
• Familiarity with healthcare regulatory environment and severity of illness/risk of mortality documentation

WHAT’S IN IT FOR YOU

• 100% remote work with flexible scheduling within EST business hours (Monday–Friday)
• Strong long-term conversion potential for candidates in approved states
• Collaborative, accountable, and supportive team environment
• Competitive medical, dental, vision, Health Savings Account, Dependent Care FSA, and supplemental coverage options
• 401k plan with company match and full vesting upon eligibility
• Paid time off, sick time, and paid company holidays
• Opportunities for professional growth, mentoring, and special project involvement
• Equal opportunity employer committed to diversity and inclusion