Clinical Documentation Integrity (CDI) Leader

$84/hr

50 people hired

RemoteUSTechnology5-8 YearsContractPosted Aug 13, 2026

About this role

You will support the evaluation and improvement of AI systems designed to enhance clinical documentation integrity, coding accuracy, and revenue-cycle workflows. The role combines CDI leadership with AI quality evaluation, focusing on DRG optimization, physician query management, HCC risk adjustment, documentation quality, and coding compliance. You will review AI-generated documentation recommendations, physician queries, and coding suggestions to ensure they are clinically accurate, compliant, and aligned with industry standards.

Responsibilities

CDI program leadership: Lead inpatient and/or outpatient clinical documentation integrity programs, including concurrent and retrospective review workflows.
AI output evaluation: Review AI-generated documentation improvement suggestions, physician queries, and coding recommendations for clinical accuracy and compliance.
Documentation review: Assess medical records to ensure accurate capture of diagnoses, procedures, severity of illness, and risk of mortality.
Physician query management: Develop and manage compliant physician query processes in accordance with AHIMA and ACDIS standards.
KPI monitoring: Track query response rates, CC/MCC capture rates, case mix index, DRG accuracy, and other CDI performance metrics.
Cross-functional collaboration: Work with coding, compliance, clinical, and revenue-cycle teams to address documentation gaps and improve workflows

Qualifications

Minimum 5+ years of experience in Clinical Documentation Integrity or Clinical Documentation Improvement, including at least 2 years in a manager or leadership role.
Deep knowledge of MS-DRG methodology, CC/MCC hierarchies, and ICD-10-CM/PCS coding guidelines.
Strong expertise in physician query management according to AHIMA and ACDIS compliant query standards.
Strong clinical background with the ability to interpret complex medical records and clinical documentation.
Proficiency with CDI platforms such as 3M, Nuance, Optum360, or equivalent systems.
Experience working with EHR platforms and clinical documentation workflows.
Strong understanding of CMS regulations, Official Coding Guidelines, and payer-specific documentation requirements.
Exceptional written and verbal English communication skills.
High attention to detail with the ability to critically evaluate AI-generated clinical and coding content.
Comfortable working independently in a fully remote environment.
Must be based in the United States.