No longer accepting applications (expired, filled, etc.)

Sage Clinical RCM, LLC

Certified Clinical Documentation Integrity (CDI) Specialist – RN or FMG

The Clinical Documentation Integrity (CDI) Specialist/Consultant provides expert guidance in clinical documentation practices to improve quality, accuracy, and compliance. This role partners with physicians, coding teams, and health information professionals to ensure documentation accurately reflects patient severity of illness, risk of mortality, and care delivered, supporting appropriate reimbursement and coding integrity.

Key Responsibilities
  • Conduct detailed concurrent and retrospective clinical documentation reviews across client sites to identify documentation improvement opportunities.
  • Collaborate with client physicians and leadership to clarify documentation and ensure accurate reflection of patient acuity and resource utilization.
  • Develop and issue compliant physician queries, adhering to AHIMA and ACDIS standards.
  • Educate and mentor client staff and providers on CDI best practices, coding principles, and documentation requirements.
  • Analyze and report CDI findings and trends, offering actionable insights and recommendations for process improvement.
  • Support client CDI program development and optimization, including workflow design, policy alignment, and performance metric tracking.
  • Participate in implementation projects for CDI software tools and workflow redesign initiatives.
  • Contribute to internal consulting knowledge base by sharing clinical, coding, and operational insights with peers and leadership.
  • Represent the firm professionally with clients, maintaining confidentiality, accuracy, and high standards of consulting integrity.
  • Travel up to 10% (as needed) for onsite assessments, education sessions, and client engagement activities.
Required
  • MD, DO, RN, or RHIA required.
  • CCDS or CDIP certification required.
  • 3–5 years of progressive CDI experience in acute care or consulting environments.
  • Strong knowledge of ICD-10-CM/PCS, MS-DRG, APR-DRG, risk adjustment and clinical coding guidelines.
  • Proven success in provider engagement and interdisciplinary collaboration.
  • Excellent written and verbal communication with a consultative and professional demeanor.
  • Strong analytical and problem-solving abilities.
  • High proficiency in EHR and CDI technology (Epic, Cerner, Iodine, 3M, Nuance, or equivalent).
  • Ability to balance multiple client projects with attention to detail and timelines.
  • Independent, adaptable, and collaborative work style suited for a dynamic consulting environment.
Preferred
  • CCS Preferred
  • Experience supporting CDI or coding improvement initiatives in multiple facility or health system settings preferred.
  • Prior consulting firm experience or multi-client CDI support background.
  • Exposure to outpatient CDI and risk-adjusted quality measures (e.g., HCCs, MIPS).
  • Advanced education or training in clinical data analytics or quality improvement.
Company Overview

Industry: Healthcare Technology

Company Size: 500-1,000 employees

Founded: 2015

Headquarters: San Francisco, CA

Key Contacts

Contact information not available

About the Company

Leading healthcare technology company focused on improving patient outcomes through innovative digital solutions. We're transforming the way healthcare is delivered with cutting-edge technology and data-driven insights. Our platform serves over 10,000 healthcare professionals and has processed millions of patient interactions.

Recent News & Updates
Series B Raised $50M Series B funding - Jan 2024
Award Named "Best Healthcare Startup" by TechCrunch - Dec 2023
Growth Expanded to 5 new states - Nov 2023
Description

Position Summary:

The Clinical Documentation Integrity (CDI) Specialist/Consultant serves as a trusted advisor to client organizations, providing expert guidance in clinical documentation practices that improve quality, accuracy, and compliance. This role combines clinical expertise, coding knowledge, and consultative skill to assess, educate, and support client CDI programs across diverse healthcare settings.

The incumbent will partner with physicians, coding teams, and health information professionals to ensure documentation accurately represents the patient’s severity of illness, risk of mortality, and care delivered—driving appropriate reimbursement and coding integrity.

Requirements

Key Responsibilities:

  • Conduct detailed concurrent and retrospective clinical documentation reviews across client sites to identify documentation improvement opportunities.
  • Collaborate with client physicians and leadership to clarify documentation and ensure accurate reflection of patient acuity and resource utilization.
  • Develop and issue compliant physician queries, adhering to AHIMA and ACDIS standards.
  • Educate and mentor client staff and providers on CDI best practices, coding principles, and documentation requirements.
  • Analyze and report CDI findings and trends, offering actionable insights and recommendations for process improvement.
  • Support client CDI program development and optimization, including workflow design, policy alignment, and performance metric tracking.
  • Participate in implementation projects for CDI software tools and workflow redesign initiatives.
  • Contribute to internal consulting knowledge base by sharing clinical, coding, and operational insights with peers and leadership.
  • Represent the firm professionally with clients, maintaining confidentiality, accuracy, and high standards of consulting integrity.
  • Travel up to 10% (as needed) for onsite assessments, education sessions, and client engagement activities.

Qualifications

Education & Credentials:

  • MD, DO, RN, or RHIA required.
  • CCDS or CDIP certification required.
  • CCS Preferred

Experience

  • 3–5 years of progressive CDI experience in acute care or consulting environments.
  • Strong knowledge of ICD-10-CM/PCS, MS-DRG, APR-DRG, risk adjustment and clinical coding guidelines.
  • Proven success in provider engagement and interdisciplinary collaboration.
  • Experience supporting CDI or coding improvement initiatives in multiple facility or health system settings preferred.

Skills & Competencies

  • Excellent written and verbal communication with a consultative and professional demeanor.
  • Strong analytical and problem-solving abilities.
  • High proficiency in EHR and CDI technology (Epic, Cerner, Iodine, 3M, Nuance, or equivalent).
  • Ability to balance multiple client projects with attention to detail and timelines.
  • Independent, adaptable, and collaborative work style suited for a dynamic consulting environment.

Preferred Qualifications

  • Prior consulting firm experience or multi-client CDI support background.
  • Exposure to outpatient CDI and risk-adjusted quality measures (e.g., HCCs, MIPS).
  • Advanced education or training in clinical data analytics or quality improvement.

About Sage Clinical RCM

Sage is a healthcare advisory firm specializing in data analytics an subject matter experts with deep clinical knowledge and certifications to support our clients in Clinical Documentation Integrity, Coding Optimization, and Revenue Cycle Transformations. We partner with hospitals, health systems, and physician enterprises nationwide to improve documentation accuracy, compliance, and financial performance through expert-led, data-driven solutions.
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