Job Description
Clinical Documentation Integrity (CDI) Specialist Remote | Full-Time | United States
Company Description
Vee Healthtek delivers cutting-edge solutions that transform healthcare organizations. We offer a comprehensive suite of services that leverage our industry expertise to provide the best possible value to our clients. By creating customized strategies, we address specific challenges and provide growth opportunities. Our technology-driven services empower organizations to improve workflows, increase cost efficiency, and streamline business processes. With a track record of success, Vee Healthtek is the partner of choice for organizations looking to invest in innovation and drive sustainable growth. Learn more at https://www.veehealthtek.com.
Position Summary
Vee Healthtek is seeking an experienced Clinical Documentation Integrity (CDI) Specialist to perform concurrent inpatient documentation reviews that improve the accuracy, completeness, and clinical integrity of the medical record. The role partners with physicians, coding, case management, and quality teams to support compliant documentation, accurate MS-DRG assignment, severity of illness (SOI), risk of mortality (ROM), quality outcomes, and revenue integrity.
Key Responsibilities
- Perform concurrent inpatient documentation reviews to identify opportunities for improved documentation specificity, clinical validation, and coding accuracy.
- Conduct compliant physician queries following AHIMA/ACDIS guidance to clarify conflicting, incomplete, or ambiguous documentation.
- Support accurate ICD-10-CM/PCS coding, MS-DRG/APR-DRG assignment, POA indicators, CC/MCC capture, SOI/ROM, PSIs, HACs, and quality metrics.
- Perform clinical validation reviews for high-impact diagnoses including sepsis, acute respiratory failure, AKI, encephalopathy, malnutrition, and other complex conditions.
- Collaborate with coding, CDI, quality, and physician teams to improve documentation quality and reduce denials.
- Provide physician and CDI education based on documentation trends and audit findings.
- Monitor productivity, quality, and compliance standards while participating in internal audits and continuous improvement initiatives.
- Maintain current knowledge of CMS regulations, ICD-10-CM/PCS, Coding Clinic, AHIMA, and ACDIS guidance.
Qualifications
- Must have Active RN license or graduate of an accredited medical program (MD, DO, MBBS, NP, PA, or equivalent clinical background).
- CCDS or CDIP certification required.
- Minimum 5 years of concurrent inpatient CDI experience in an acute care hospital.
- Strong knowledge of MS and APR-DRG reimbursement, ICD-10-CM/PCS, clinical validation, and compliant query practices.
- Experience with Epic, Cerner, Solventum 360, Iodine, SmarterDx, or similar CDI platforms.
- Excellent clinical judgment, communication, presentation, and interdisciplinary collaboration skills.
Required Knowledge
- MS-DRGs, APR-DRGs, SOI/ROM, POA, PSIs, HACs, Vizient, Elixhauser, CMS IPPS, AHA Coding Clinic, and AHIMA/ACDIS query guidance.
Success Measures
- Meet established productivity and quality benchmarks.
- Improve documentation accuracy and physician engagement.
- Support denial prevention and compliant reimbursement.
- Contribute to continuous education and process improvement.
