Job Details

Clinical Documentation Integrity (CDI) Specialist II (Remote)

A Brief Overview The Clinical Documentation Integrity Specialist is responsible for utilizing independent clinical judgement in facilitating the integrity, overall quality, accuracy and completeness of provider-based clinical documentation in the medical record. This position is responsible for collaborating with healthcare providers to ensure the documentation in the medical record accurately reflects the patient complexity and resource utilization. The CDI Specialist assesses the clinical documentation through extensive review of the medical record, interacts with multiple members of the healthcare team, educates and assists the clinical areas in effective and compliant documentation. The CDI Specialist provides guidance with processes in the clinical departments to support accurate, timely and complete documentation in agreement with company policies and procedures.

What You Will Do

• Ensures documentation is accurate and complete by performing timely medical record review and determination of code assignment by applying clinical and/or coding expertise to identify opportunities for improved or clarified documentation that accurately reflects the patient complexity and resource utilization.
• Direct and timely follow-up with clinical providers to ensure requested clarification is provided.
• Responsible and accountable for expanding CDI and coding knowledge (keeping up to date on latest research, technology, treatment modalities, etc.)
• Utilizes critical thinking/problem solving processes
• Appropriately utilizes and interprets professional association resource materials and regulatory agencies guidelines to enhance own skill sets: Coding Clinics, AHIMA, CMS guidelines
• Identifies query opportunities for record integrity
• Is proficient in query writing so that the question is easily understood by the physician
• Query writing is AHIMA compliant per practice briefs
• Escalates non-response to query by physicians immediately according to query escalation policy
• Collaborates with the coding team
• Demonstrates proficiency in reviewing increasingly complex cases.
• Demonstrates proficiency and efficiency in cross covering for other units, specialties and hospitals as assigned.
• Actively engages in educating physicians and other clinical care providers regarding clinical documentation in a variety of formats including participation in clinical rounding, service line focused education sessions and one to one case specific feedback.
• Consistently provides a collaborative relationship with healthcare team providers/members
• Participates in service line rounding/touch-point routinely.
• Provides ongoing service line directed education to provider teams
• Applies knowledge of health care workflows in order to work collaboratively with medical staff and other health care team members to improve the overall accuracy and comprehensiveness of medical record documentation, with focus on ensuring accurate reporting of quality outcomes.
• Seeks and provides feedback for improved CDI practice and integrity/quality of medical record documentation.
• Identifies opportunity utilizing resources and follows department guidelines for processes
• Comprehends the impact of accurate clinical documentation in the medical record: accurate billing, public reporting, research data, quality metrics, provider scorecards, etc.
• Meets established operational and productivity standards.
• Consistently meets productivity, quality, and ethical standards.
• Proficient and efficient use of the CDI business platform
• Serves as a mentor to other Clinical Documentation Specialists, participates in committees

Qualifications

Education Associate's Degree in health related field (Required) or Other Accredited Program: Diploma in RN (Required) Bachelor's Degree in health related field (Preferred) Work Experience 2+ years in CDI Specialist role (Required) 3+ years clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required) Experience using clinical computer systems (Required) Knowledge, Skills, & Abilities Must have thorough, up-to-date clinical skills (i.e. current working knowledge of pathology, pharmacology, surgical procedures, etc.). (Required proficiency) Excellent written and verbal communication skills including presentations. (Required proficiency) Ability to function independently and as a team player in a fast-paced environment. (Required proficiency) Detail-oriented, and relationship building skills. (Required proficiency) Demonstrates and has extensive knowledge of disease pathophysiology (Required proficiency) Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e., printers, copy machine, FAX machine, etc.). (Required proficiency) Licenses and Certifications Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire) or Registered Health Information Administration (RHIA) (Required) or Registered Health Information Technologist (RHIT) (Required) and Certified Clinical Documentation Specialist (CCDS) (Required) or Clinical Documentation Improvement Practitioner (CDIP) (Required) Physical Demands Standing Occasionally Walking Occasionally Sitting Constantly Lifting Rarely up to 20 lbs Carrying Rarely up to 20 lbs Pushing Rarely up to 20 lbs Pulling Rarely up to 20 lbs Climbing Rarely up to 20 lbs Balancing Rarely Stooping Rarely Kneeling Rarely Crouching Rarely Crawling Rarely Reaching Rarely Handling Occasionally Grasping Occasionally Feeling Rarely Talking Constantly Hearing Constantly Repetitive Motions Frequently Eye/Hand/Foot Coordination Frequently Travel Requirements 10%

Primary Location

: United States-Ohio-Shaker_Heights

Work Locations

: 3605 Warrensville Center Road 3605 Warrensville Center Road Shaker Heights 44122

Job

: Finance / Accounting

Organization

: UHHS_Revenue_Cycle

Schedule

: Full-time

Employee Status

: Regular - Shift Days

Job Type

: Standard

Job Level

: Professional

Travel

: No Remote Work : Yes

Job Posting

: Aug 24, 2026, 1:23:49 PM