Cdi Specialist - Health Information Job at Rady Children's Hospital-San Diego (Remote)

Senior Clinical Documentation Specialist (CDI)

Our client is seeking an experienced Senior Clinical Documentation Specialist (C...

Location

United States , Tampa

Salary:

35.00 - 50.00 USD / Hour

Medasource

Expiration Date

Until further notice

Requirements

Associate’s Degree in Nursing, Health Information Management (HIM), or a related healthcare field
Minimum 6 years of acute care Clinical Documentation Improvement (CDI) experience
Strong understanding of ICD-10-CM/ICD-10-PCS coding, Medicare/Medicaid/commercial payer guidelines, and clinical documentation improvement practices
Proven ability to independently develop compliant provider queries and collaborate directly with providers
Experience with at least two of the following: Optum 360 eCAC, Cerner EHR, Vizient
Strong inpatient CDI background
Strong written and verbal communication skills
Critical thinking and problem-solving ability
Ability to work independently in a remote environment

Job Responsibility

Review medical records for documentation quality, completeness, and accuracy
Identify gaps, conflicting documentation, and unspecified diagnoses
Develop compliant provider queries to improve documentation specificity
Ensure documentation accurately reflects severity of illness and risk of mortality
Collaborate directly with physicians and clinical staff through meetings, rounding, Zoom calls, phone calls, and email
Assist with provider education related to documentation improvement practices
Utilize clinical judgment, NLP tools, and CDI software platforms to support documentation review
Partner with HIM coding teams to support accurate reimbursement and reporting outcomes
Support onboarding and mentoring of junior CDI team members
Participate in operational and leadership-driven CDI initiatives and special projects

What we offer

100% remote work with flexible scheduling within EST business hours (Monday–Friday)
Strong long-term conversion potential for candidates in approved states
Collaborative, accountable, and supportive team environment
Competitive medical, dental, vision, Health Savings Account, Dependent Care FSA, and supplemental coverage options
401k plan with company match and full vesting upon eligibility
Paid time off, sick time, and paid company holidays
Opportunities for professional growth, mentoring, and special project involvement

Fulltime

Hospital Coding Educator - Health Information

Location

United States , West Allis

Salary:

33.05 - 49.60 USD / Hour

Advocate Aurora Health

Expiration Date

Until further notice

Requirements

Coding Specialist (CCS) certification issued by the American Health Information Management Association (AHIMA)
Health Information Administrator (RHIA) registration issued by the American Health Information Management Association (AHIMA)
Health Information Technician (RHIT) registration issued by the American Health Information Management Association (AHIMA)
Associate's Degree in Health Information Management or related field
Typically requires 5 years of experience in hospital coding for a large complex health care system, which includes hospital coding, denial review and/or coding education functions
Demonstrated leadership skills and abilities
Demonstrates knowledge of National Council on Compensation Insurance, Inc. (NCCI) edits, and local and national coverage decisions
Expert knowledge and experience in ICD-10-CM/PCS and CPT coding systems, G-codes, HCPCS codes, Current Procedural Terminology (CPT), modifiers, and Ambulatory Patient Categories (APC), MS-DRGs (Diagnosis related groups)
Advanced knowledge in Microsoft Applications, including but not limited to
Excel, Word, Powerpoint,Teams

Job Responsibility

Responsible for delivering education sessions within the coder education program, including the remote onboarding program and ongoing coder education
Coordinates training and orientation of new staff, lead training sessions and present high-level education on coding guidelines/information to coders and trainees, which includes presenting PowerPoint presentations and webinar-type meetings
Per the direction of the Coding Training and Education Manager, work with the Coding Production leadership to identify promotional and cross-training opportunities for coders depending on their skill level and performance
Assesses coders’ comprehension of training, and track and reports coding education results to coding leadership
Identifies need for one-on-one coding sessions and develops follow-up educational plans as needed
Collaborates with coding leadership to ensure coders receive sufficient and focused education
Independently develops and maintains coding educational tools/resources, including training curriculum and training handbook, presentations, web-based coding education programs, learning and training materials
Researches coding guidelines and updated coding information as published in ICD-10-CM/PCS, CPT and HCPCS coding systems, and communicates any changes and new findings to coding staff
Maintain knowledge of ICD-10 and CPT and MS-DRG classifications and coding of diagnoses and procedures
Clarifies changes in coding guidance or coding educational materials

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

New

Inpatient Coding Team Lead

Baptist Medical Center Jacksonville is currently hiring for a Full-time Team Lea...

Location

United States , Jacksonville

Salary:

Not provided

Baptist Health (Florida)

Expiration Date

Until further notice

Requirements

High School Diploma
3-5 Years Experience working in an Acute Care setting
Knowledge base in Coding Clinic Guidelines
Knowledge base in Physiology
Knowledge base in Anatomy
Coding Experience
Knowledge of State and Federal Requirements
Leadership Experience
Registered Health Information Administrator - AHIMA
Registered Health Information Technician (RHIT) - AHIMA

Job Responsibility

Responsible for correctly identifying and assigning diagnosis and procedure codes using the ICD-10-CM/PCS Classification System to each patient's record for optimization in accordance with State and Federal requirements on Inpatient accounts
Be knowledgeable of CPT codes, edit resolution and assigning CPT-4 Codes on Observation accounts when applicable
Verifies and submits abstracted UB04 information across the billing system for claim submission
Must efficiently complete this activity for 100% of patient's discharged records daily to maintain the Coding A/R goals set forth
Works ACHA, DNFB and Post Bill error reports, such as A/B rebills, Claim Edits, and Denials when applicable
Advises and coordinates with Management, CDI and HIM on coding documentation
Provides support to Coders, CDI and other staff via mentorship, and possesses auditing and training skills
Requires critical thinking skills, effective communication skills, decisive judgement and the ability to work with minimal supervision
Must be focused and detailed oriented and have effective time management skills
Proficient in basic computer skills and able to utilize a computerized encoder and EHR

Fulltime

New

Clinical Documentation Integrity (CDI) Analyst

Applies clinical expertise and knowledge of health care workflows in order to ed...

Location

United States , Shaker Heights

Salary:

79331.00 - 124051.00 USD / Year

University Hospitals

Expiration Date

Until further notice

Requirements

Other Accredited Program: Diploma in Nursing or in Health Information Management
Associate's Degree preferably in Health Information Management or Nursing
Bachelor's Degree preferably in Health Information Management or Nursing
Doctorate Degree in Medicine
3+ years CDI experience as a concurrent reviewer
Extensive clinical knowledge and understanding of pathology/physiology
Strong critical thinking skills
Demonstrates comprehension of Case Mix Index (CMI)
Knowledge of age-specific patient needs and the elements of disease processes and related procedures
Excellent written and verbal communication skills

Job Responsibility

Performs post-discharge, final coded, pre-bill reviews of targeted records identified for second-level review for opportunity to accurately capture patient acuity, severity of illness, risk of mortality, and DRG assignment in compliance with industry rules and regulations
Documents SLR findings within CDI application
Serves as a role model and resource for CDI team members
Maintains a summary of opportunities identified through second level review for feedback and education with the CDI team
Periodically review the criteria established for cases triggering a second level review and recommend updates or modifications to the criteria to assist in identifying areas of opportunity
Is actively engaged in quality and process improvement efforts
Performs other duties as assigned
Complies with all policies and standards
Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients

What we offer

$5,000 Sign on Bonus
healthcare
dental
vision
retirement plan options
additional offerings

Fulltime

Cdi Query Writer

The CDI Query Writer is responsible for facilitating and distributing compliant ...

Location

United States

Salary:

Not provided

Accuity Healthcare

Expiration Date

Until further notice

Requirements

Foreign Medical Graduate
Associate's degree in nursing
Bachelor’s degree in nursing
Bachelor’s degree in health information management
Other related degree will be reviewed as the discretion of management
Minimum 3 years of clinical work experience
Minimum 2 years of current Inpatient CDI experience
MD, DO, CDIP, RN, BSN, CCS, or CCDS
Excellent communication skills
Very strong writing skills, appropriate punctuation, grammar etc.

Job Responsibility

Assess the clinical indicators and suggestions of various query requests received from the MD Reviewer/ DRG Integrity Specialist
Collaborate and communicate as necessary to clarify and avoid misinterpretation to ensure the query is optimally written and distributed to the correct client provider
Creates queries in a compliant manner in accordance with AHIMA and ACDIS compliant query guidelines as well as American Hospital Association (AHA) Coding Clinic Guidelines, ensuring that proper medical diagnoses and procedures are being submitted for reimbursement
Constructs queries with attention to detail, utilizing proper grammar and punctuation
Utilizes ICD-10 coding guidelines and medical terminology to expertly create a query which results in improved accuracy of patient severity of illness, and/or risk of mortality representing the patient’s true clinical picture in final code assignment
Participates in all educational opportunities provided by Accuity for updates in current coding and query writing guidelines as well as internal and client policies and procedures
Utilizes Accuity policies and procedures, as well as Federal and State coding reimbursement guidelines, and application of correct coding guidelines to ensure the documentation supports code assignment is at the greatest level of specificity
Will competently use Accuity tracking tool for data entry for reportable criteria
Maintains expected productivity and quality standards
Performs miscellaneous job-related duties as assigned

Hospital Based Inpatient Coder III

Utilizing an electronic medical record and computerized encoder, assigns and seq...

Location

United States , Miramar

Salary:

Not provided

Memorial Healthcare System

Expiration Date

Until further notice

Requirements

High School Diploma or Equivalent
Certified Coding Associate (CCA) - American Health Information Management Association (AHIMA)
Three (3) years inpatient coding experience in a hospital setting or a graduate of the MHS coder intern program
Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS)
Proficient in basic computer skills and ability to utilize a computerized encoder and electronic medical record system
Requires critical thinking skills, effective communication skills, decisive judgment and the ability to work with minimal supervision
Must be able to work in a stressful environment and take appropriate action

Job Responsibility

Assigns and sequences diagnosis and procedure codes and present on admission indicators for inpatient encounters based on medical record documentation in accordance with Official Coding Guidelines, CMS regulations, encoder software guidance and Health Information Management (HIM) policies and procedures
Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements
Formulates physician queries for validation of pathological findings
Requests clinical validation queries for Clinical Documentation Integrity (CDI) review and follow-up
Seeks clarification from providers or other designated resources to ensure accurate and complete coding
Attends educational meetings and seminars to maintain certification and continuing education requirements
Reviews appropriate inpatient coding work queues daily to address coding edits and needed corrections and follows procedure to notify billing as needed
Reviews accounts and performs needed correction for internal audits and external denials
Reviews inpatient medical records to assign and sequence all appropriate diagnosis and procedure codes utilizing encoder software and following official coding guidelines
Reviews Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) for appropriate code assignment

Fulltime

Inpatient/DRG Validation Coding Auditor

The Inpatient/DRG Validation Coding Auditor is responsible for reviewing acute i...

Location

United States , Sharonville

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

5+ years inpatient coding experience
3+ years facility coding audit experience (DRG/APC validation)
Strong knowledge of reimbursement methodologies and DRG payment systems
Proficiency in EMRs, encoders, proprietary audit systems, and Microsoft Office
Deep understanding of HIPAA and confidentiality requirements
Strong analytical, written, and verbal communication skills
Solid grasp of medical and surgical terminology
Bachelor’s Degree or equivalent experience
Required certification (CCS preferred): CPC (Certified Professional Coder)
CCS (Certified Coding Specialist)

Job Responsibility

Perform detailed audits of inpatient records to validate ICD-10-CM/PCS coding, DRG assignment (MS-DRG, APR-DRG, TRICARE), and clinical documentation accuracy
Ensure documentation supports coded diagnoses, procedures, severity of illness, and resource utilization
Identify overpayments and underpayments through claim analysis (including 30-day lookbacks)
Provide clear, compliant audit recommendations aligned with Official Coding Guidelines and AHA Coding Clinics
Partner with CDI specialists to identify documentation improvement and query opportunities
Maintain productivity, quality standards, and client turnaround expectations
Stay current on regulatory changes, reimbursement policies, and coding updates
Contribute to process improvement initiatives and compliance risk identification

What we offer

medical
vision
dental
life and disability insurance
company 401(k) plan

Inpatient/DRG Validation Coding Auditor

The Inpatient/DRG Validation Coding Auditor is responsible for reviewing acute i...

Location

United States , Sharonville

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

5+ years inpatient coding experience
3+ years facility coding audit experience (DRG/APC validation)
Strong knowledge of reimbursement methodologies and DRG payment systems
Proficiency in EMRs, encoders, proprietary audit systems, and Microsoft Office
Deep understanding of HIPAA and confidentiality requirements
Strong analytical, written, and verbal communication skills
Solid grasp of medical and surgical terminology
Bachelor’s Degree or equivalent experience
Required certification (CCS preferred): CPC (Certified Professional Coder)
CCS (Certified Coding Specialist)

Job Responsibility

Perform detailed audits of inpatient records to validate ICD-10-CM/PCS coding, DRG assignment (MS-DRG, APR-DRG, TRICARE), and clinical documentation accuracy
Ensure documentation supports coded diagnoses, procedures, severity of illness, and resource utilization
Identify overpayments and underpayments through claim analysis (including 30-day lookbacks)
Provide clear, compliant audit recommendations aligned with Official Coding Guidelines and AHA Coding Clinics
Partner with CDI specialists to identify documentation improvement and query opportunities
Maintain productivity, quality standards, and client turnaround expectations
Stay current on regulatory changes, reimbursement policies, and coding updates
Contribute to process improvement initiatives and compliance risk identification

What we offer

medical
vision
dental
life and disability insurance
company 401(k) plan

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Cdi Specialist - Health Information

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