Clinical Documentation Integrity (CDI) Leader

our client is working with a leading AI research lab to improve the capabilities of next-generation AI systems. We are seeking experienced Clinical Documentation Integrity (CDI) managers and leaders to evaluate AI tools designed to enhance clinical documentation accuracy and coding integrity workflows. Your expertise in DRG optimisation, HCC risk adjustment, physician query management, and clinical documentation best practices will directly inform AI systems that improve documentation quality, compliance, and revenue integrity.

**Responsibilities**

• Lead clinical documentation integrity programs for inpatient and/or outpatient settings, overseeing concurrent and retrospective review workflows.

• Evaluate AI-generated clinical documentation improvement suggestions, physician queries, and coding recommendations for clinical accuracy and compliance.

• Conduct and review clinical documentation to ensure accurate capture of diagnoses, procedures, severity of illness, and risk of mortality.

• Develop and manage physician query processes in alignment with AHIMA and ACDIS guidelines.

• Monitor CDI program KPIs including query response rates, CC/MCC capture rates, case mix index, and DRG accuracy.

• Collaborate with coding, compliance, and clinical teams to address documentation gaps and improve query processes.

• Provide education to physicians and clinical staff on documentation requirements and best practices.

• Ensure compliance with Official Coding Guidelines, CMS regulations, and payer-specific requirements.

• Annotate AI outputs and provide structured clinical feedback to support AI training datasets.

**Requirements**

• 5+ years of experience in clinical documentation integrity or improvement, with at least 2 years in a manager or leadership role.

• Deep knowledge of MS-DRG methodology, CC/MCC hierarchies, and ICD-10-CM/PCS coding guidelines.

• Expertise in physician query management per AHIMA and ACDIS compliant query standards.

• Strong clinical background with the ability to interpret medical records and clinical documentation.

• Proficiency with CDI software platforms (3M, Nuance, Optum360, or equivalent) and EHR systems.

• Exceptional written and verbal English communication skills.

• High attention to detail with the ability to critically evaluate clinical documentation and AI-generated outputs.

• Comfortable working independently in a fully remote environment.

**Preferred Qualifications**

• CCDS (Certified Clinical Documentation Specialist) or CDIP (Clinical Documentation Improvement Practitioner) credential.

• Experience with HCC risk adjustment and outpatient CDI programs.

• Background in RN, RHIA, CCS, or similar clinical or coding credential.

• Familiarity with AI-assisted CDI tools (e.g., Nuance DAX, 3M M\*Modal) and comfort evaluating AI-generated clinical content.

• Experience presenting CDI performance metrics to clinical and executive leadership.

**Why Join?**

• Contribute to the development of frontier AI systems in healthcare.

• Collaborate with a world-class AI research organisation.

• Gain exposure to cutting-edge AI workflows in clinical documentation and revenue cycle management.

• Opportunity to work on high-impact projects shaping the future of healthcare AI.