Berkeley Research Group, LLC
Healthcare Clinical Documentation Integrity (CDI) Consultant
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Job Description
- Req#: JR100370
Employer Industry: Healthcare Consulting
Why consider this job opportunity:
- Salary up to $150,000 per year
- Competitive sign-on bonus to welcome exceptional talent
- Opportunity for career advancement and growth within the organization
- Flexibility for remote work or on-site presence in New York City
- Work with a collaborative team of experts in clinical documentation and healthcare performance improvement
- Engage in meaningful work that directly impacts patient care and documentation quality
What to Expect (Job Responsibilities):
- Review inpatient medical records for identified payer populations on admission and throughout hospitalization
- Analyze clinical information to identify areas within the chart for potential gaps in physician documentation
- Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff
- Work collaboratively with the coding staff to ensure documentation reflects the patient’s clinical status and care
- Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement
What is Required (Qualifications):
- 4-7 years of experience as a Clinical Documentation Improvement (CDI) Specialist within a hospital setting or as a CDI consultant
- RN, BSN, or Health Information Management degree required
- Currently licensed as a Registered Nurse – ICU, OR, or ED specialty preferred
- Minimum 2 years of inpatient coding experience with ICD-10 CM/PCS preferred
- Strong knowledge of CDI principles and ability to audit medical records
How to Stand Out (Preferred Qualifications):
- ACDIS or AHIMA certification preferred
- Experience in clinical documentation improvement, coding, audit, or Health Information Management
- Familiarity with hospital systems such as EPIC, MEDITECH, or similar platforms
- Strong proficiency in MS Office applications, including Word, PowerPoint, Excel, and Outlook
- Excellent time management skills and the ability to handle multiple priorities effectively
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