Description:
The CDI Specialist / Consultant serves as a trusted advisor to client organizations, offering expert guidance on clinical documentation practices that enhance accuracy, quality, and compliance. This role blends clinical expertise, coding knowledge, and consulting skills to assess, educate, and support CDI programs across diverse healthcare settings.
You’ll partner with physicians, coding teams, and health information professionals to ensure documentation accurately reflects patient acuity, risk, and care delivered—supporting appropriate reimbursement and data integrity.
Key Responsibilities- Perform concurrent and retrospective reviews to identify documentation improvement opportunities.
- Collaborate with physicians and leadership to clarify documentation and ensure accuracy.
- Develop compliant physician queries (AHIMA & ACDIS standards).
- Educate and mentor providers and staff on CDI best practices and coding principles.
- Analyze CDI trends and provide actionable recommendations.
- Support CDI program optimization, workflow design, and metric tracking.
- Participate in CDI technology implementations and process redesign initiatives.
- Maintain professionalism, confidentiality, and consulting integrity.
- Travel: Up to 10% for client visits and training.
Requirements:
Qualifications- MD, DO, RN, or RHIA required
- CCDS or CDIP required; CCS preferred
- 3–5 years of CDI experience in acute care or consulting
- Strong knowledge of ICD-10-CM/PCS, MS-DRG, APR-DRG, and risk adjustment
- Excellent communication, analytical, and problem-solving skills
- Proficiency in Epic, Cerner, Iodine, 3M, Nuance, or similar CDI/EHR systems
- Able to manage multiple projects and work independently in a dynamic setting
Preferred- Prior consulting or multi-client CDI experience
- Knowledge of outpatient CDI and risk-adjusted quality measures (HCCs, MIPS)
- Advanced education or training in data analytics or quality improvement
Why Join Sage Clinical RCMAt Sage Clinical RCM, we’re a team of healthcare and data experts dedicated to improving documentation accuracy and compliance through collaboration, education, and innovation.
We offer:
- A flexible, remote-friendly work environment
- Professional development and certification reimbursement
- Opportunities to impact national health systems through meaningful CDI transformation