CDI Quality Reviewer; Remote

Overview

The CDI Quality Reviewer is responsible for concurrent and retrospective review of clinical documentation to identify opportunities that improve documentation accuracy, quality reporting, and audit readiness. This role focuses on validating clinical indicators, supporting compliant coding, and strengthening defensibility across inpatient records. The CDI Quality Reviewer works collaboratively with CDI, coding, and audit teams to support high-quality documentation outcomes. This is a fully remote role focused on quality, compliance, and continuous improvement.

• Perform concurrent and retrospective reviews of inpatient medical records to assess documentation completeness and accuracy
• Validate clinical indicators supporting reported diagnoses and procedures
• Identify documentation gaps impacting DRG assignment, SOI/ROM, and quality metrics
• Flag documentation risks that may affect audits, denials, or compliance
• Provide clear, written review notes and recommendations aligned with official coding and CDI guidelines
• Collaborate with CDI, coding, and audit teams to share findings, trends, and improvement opportunities
• Support audit defense and documentation quality initiatives as needed
• Maintain quality and productivity standards while working independently in a remote environment

• Active RN license or other applicable clinical license
• Minimum 3–5 years of CDI, inpatient coding, or clinical documentation review experience, including both concurrent and retrospective review
• One of the following credentials required: CDIP, CCDS, or CCS
• Strong understanding of DRGs, SOI/ROM, and inpatient documentation standards
• Knowledge of Official Coding Guidelines and ACDIS/AHIMA practices
• Ability to analyze complex clinical documentation and apply critical thinking
• Comfortable working independently in a fully remote role

• Experience supporting external audits or payer reviews
• Exposure to multiple service lines, including medicine, surgery, and critical care
• Experience working in Epic or other major EHRs