About this role
Lead evaluation and improvement of clinical documentation integrity by applying CDI leadership experience to assess AI-generated documentation suggestions, physician queries, and coding recommendations. This role focuses on ensuring accurate capture of diagnoses, procedures, severity of illness, and risk adjustment, and on guiding AI systems to improve documentation quality, compliance, and revenue integrity across inpatient and outpatient workflows.
Key Responsibilities- Lead CDI programs for inpatient and/or outpatient settings, managing concurrent and retrospective review workflows.
- Evaluate AI-generated CDI suggestions, physician queries, and coding recommendations for clinical accuracy, compliance, and appropriateness.
- Conduct and review clinical documentation to ensure correct capture of diagnoses, procedures, severity of illness, and risk of mortality.
- Design, implement, and manage physician query processes consistent with AHIMA and ACDIS guidance.
- Monitor and report CDI program KPIs, including query response rates, CC/MCC capture rates, case mix index, and DRG accuracy.
- Collaborate with coding, compliance, and clinical teams to resolve documentation gaps and refine query workflows.
- Provide education and training to physicians and clinical staff on documentation requirements and best practices.
- Ensure compliance with Official Coding Guidelines, CMS regulations, and payer-specific rules.
- Annotate AI outputs and deliver structured clinical feedback to support development and training of AI datasets.
- Minimum 5 years of experience in clinical documentation integrity or improvement, with at least 2 years in a manager or leadership role.
- Deep knowledge of MS-DRG methodology, CC/MCC hierarchies, and ICD-10-CM and ICD-10-PCS coding guidelines.
- Demonstrated expertise in physician query management consistent with AHIMA and ACDIS compliant query standards.
- Strong clinical background with proven ability to interpret medical records and clinical documentation.
- Proficiency with CDI software platforms such as 3M, Nuance, Optum360, or equivalent, and experience with electronic health record systems.
- Exceptional written and verbal English communication skills.
- High attention to detail and the ability to critically evaluate clinical documentation and AI-generated outputs.
- Comfortable working independently in a fully remote environment.
- CCDS or CDIP credential.
- Experience with HCC risk adjustment and outpatient CDI programs.
- Clinical or coding credential such as RN, RHIA, or CCS.
- Familiarity with AI-assisted CDI tools, for example Nuance DAX or 3M M*Modal, and experience evaluating AI-generated clinical content.
- Experience presenting CDI performance metrics to clinical and executive leadership.
- Location: Remote.
- Employment type: hourly.
84 - 84 hourly
Eligibility- Must be able to work fully remotely and independently.
- Must have strong written and verbal English communication skills suitable for clinical review and stakeholder education.
Contribute CDI expertise to the development of next-generation AI systems in healthcare, collaborate with a leading AI research organization, gain exposure to advanced AI workflows in clinical documentation and revenue cycle management, and work on high-impact projects that shape the future of healthcare AI.