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HIM CDI Specialist, Ambulatory Care Building, Remote

February 19, 2026

<h1>Primary Location: </h1>Work from Home - KY<h1>Address: </h1>P.O. Box 909 Louisville, KY 40201-0909 <h1>Shift: </h1>First Shift (United States of America)<h1>Job Description Summary: </h1><h1>Job Description: </h1>The job summary for this position is not currently on file electronically. Please see your supervisorr or Human Resources Representative for a hard copy before you complete your acknowledgment.<h1>Additional Job Description:</h1>Job SummaryThis position is responsible for reviewing patient medical records to facilitate modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team to promote accurate capture of clinical severity of illness and risk of mortality (later translated into coded data) and to support the level of service rendered to relevant patient populations. CDIS exhibits expert knowledge of clinical documentation requirements, MS-DRG Assignment, case mix index (CMI) analysis, clinical disease classifications, major and non-major complications and comorbidities (MCCs or CCs), and quality-driven patient outcome indicators. Interacts as needed with internal customers to include but not limited to hospital staff, physicians, and other revenue cycle team members. Actively participates in department and hospital performance initiatives when needed to ensure ULH success.Responsibilities<ul><li>Completes initial medical record reviews of all inpatient patient accounts (all payers) within 24-48 hours of admission for a specified patient population to: <ul><li>(a) Evaluate and review inpatient medical records daily, concurrent with patient stay, to identify opportunities to clarify missing or incomplete documentation. </li><li>(b) Assign the principal diagnosis, pertinent secondary diagnoses, procedures for accurate MS-DRG assignment, score risk of mortality and severity of illness and initiate a review worksheet.</li><li>(c) Conduct follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary. </li></ul></li><li>Formulate clinically, compliant and credible physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary. </li><li>Proactively collaborate with physicians to discuss and clarify documentation inconsistencies to ensure accuracy of the medical record and appropriate capture of the course of treatment provided to the patient.</li><li>Educate providers about identification of disease processes that reflect SOI, complexity, and acuity to facilitate accurate application of code sets.</li><li>Gather and analyze information pertinent to documentation findings and outcomes, and use this information to develop action plans for process improvements.</li><li>Collaborate with case managers, nursing, and other ancillary staff regarding interaction with physicians concerning documentation opportunities and to resolve physician queries prior to discharge.</li><li>CDIS communicates/completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution with appropriate leadership.</li><li>Remain abreast and current on training of new hires and ongoing CDIS professional staff development as well as participate in CDI-related continuing education activities to maintain certifications and licensures.</li><li>Collaborate with HIM/coding professionals to review and resolve DRG mismatches for individual problematic cases and ensure accuracy of final coded data in conjunction with CDI managers, coding managers, and/or physician advisors.</li><li>Identify patterns, trends, variances, and opportunities to improve documentation review processes.</li><li>Aid in identification and proper classification of complication codes and present on admission (POA) determination (patient safety indicators/hospital-acquired conditions) by acting as an intermediary between coding staff and medical staff.</li><li>Contribute to a positive working environment and perform other duties as assigned or directed to enhance the overall efforts of the organization.</li></ul>Qualifications<ul><li>CDIS candidate must have and maintain current licensure as a RN, RHIA, RHIT or possess an active CCS (AHIMA) or CPC-H (AAPC) coding credential. </li><li>CDIS must have 3+ years of acute care experience as a RN or 3+ years inpatient coding experience as a RHIA/RHIT/CCS/CPC-H. </li><li>Must have advanced clinical expertise and extensive knowledge of complex disease processes with broad clinical experience in an inpatient setting.</li><li>Certified Clinical Documentation Specialist or Clinical Documentation Improvement Professional (CCDS or CDIP) credential is required within 12 months of employment.</li></ul>KNOWLEDGE, SKILLS, & ABILITIES<ul><li>Working knowledge of medical terminology and Official Coding Guidelines.</li><li>Ability to work independently, self-motivate, and adapt to the changing healthcare arena</li><li>Excellent verbal and written communication skills, analytical thinking, and problem solving with strong attention to detail</li><li>Proficiency in organizational skills and planning, with an ability multitask in a fast-paced environment</li><li>Proficiency in computer use, including database and spreadsheet analysis, presentation programs, word processing, and Internet research</li><li>Working knowledge of federal, state, and private payer regulations as well as applicable organizational policies and procedures</li><li>Working knowledge of quality improvement theory and practice, core measures, safety, and other required reporting programs</li><li>Ability to formulate clinically, compliant and credible physician queries</li></ul>

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...