Healthcare Clinical Documentation Integrity (CDI) Consultant, Anywhere

JR100370 We do Consulting Differently The Integrated Health Solutions (IHS) practice at Berkeley Research Group (BRG) provides end-to-end advisory support to healthcare providers, payers, investors, and other stakeholders navigating complex strategic, operational, financial, and clinical challenges. Led by seasoned healthcare executives, operators, and clinicians, IHS partners with organizations to drive sustainable performance improvement and long-term growth through strategic growth design, operating model transformation, AI and digital enablement, clinical quality and patient care optimization, and revenue strategy—helping clients build resilient, future-ready healthcare enterprises in an increasingly complex environment. Our four core service offerings include: · Business Transformation Advisory · Margin & Operational Improvement · Quality Improvement & Clinical Care · AI & Digital Solutions Clinical and Quality Transformation (CQT) helps providers improve care for their patients by implementing evidence-based leading practices to enhance clinical quality, operational efficiency, and care delivery. CQT’s broad-based engagements help providers transform how they deliver care through a combination of reduced complications and mortality, optimizing surgery quality and operations, improved throughput and length-of-stay reduction, improved emergency department performance, quality infrastructure enhancements, and more accurate clinical coding and documentation—helping organizations deliver better patient care and outcomes while most effectively utilizing their clinical resources and infrastructure. CQT is currently seeking a Consultant or Managing Consultant to join our Case Mix Integrity team, with a focus on Clinical Documentation Integrity (CDI). The CDI Consultant/Managing Consultant works closely with the client’s CDI team, supporting classroom education and mentoring. They are responsible for ensuring the successful transfer of CDI best practices from the consulting team to the client team. The Consultant/Managing Consultant also facilitates accurate documentation for severity of illness (SOI) and quality in the medical record, which involves extensive record review and interaction with physicians, health information management professionals, coding professionals, and nursing staff. Job title and compensation will be determined based on qualifications and experience. We are hiring for several roles at a variety of levels. If you are a CDI professional and do not meet all of the listed criteria, we still encourage you to apply. Flexibility for travel (50-75%) is required for this position. Travel volume is dependent on project and client needs. Responsibilities:

• Demonstrate extensive knowledge of clinical documentation requirements and coding guidelines applicable to inpatient care and outpatient care settings.
• Review inpatient medical records for identified payer populations on admission and throughout hospitalization.
• Provide input for complete and accurate client deliverables and make valuable contributions as a team member to expert reports.
• Analyze clinical information to identify areas within the chart for potential gaps in physician documentation.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality measures, and patient safety indicators (PSI).
• Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses, and ancillary staff.
• Work collaboratively with the coding staff to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient’s clinical status and care.
• Develop and implement plans for education of physician, nursing, and ancillary staff on documentation improvement.
• Provide Interim CDS support per client need.

Requirements:

• A Bachelor's degree in a related discipline is required, preferably RN, BSN, or Health Information Management.
• A minimum of 4 years of experience as a Clinical Documentation Improvement Specialist (CDI) Specialist within a hospital setting, or as a CDI consultant, or a combination thereof, is required.
• Minimum 2 years of inpatient coding experience with ICD-10 CM/PCS preferred.
• CCDS, CCS, or CDIP Certification is required; RHIA, RHIT, CRC, or CPC certification is highly preferred.
• Possesses knowledge of DRG coding guidelines.
• Possess thorough understanding of the legal and compliance issues as they pertain to clinical documentation and coding.
• Prior experience and proficiency in Electronic Record systems such as Epic, Meditech, Cerner, 3M 360, or similar platforms.
• Proficiency in understanding and delivering education in All Patient Refined Diagnosis Related Group (APR DRG’s).
• Experience in the delivery of CDI Education to clients regarding appropriate diagnoses for capturing accurate Severity of illness, Hierarchical Condition Category (HCC’s) and Medicare Severity Diagnosis Related Group (MS DRG’s)
• Prior experience in the review and analysis of health records to identify relevant diagnoses and procedures for distinct patient encounters.
• Ability to assist with the development of CDI and HIM training and consulting tools and methodologies.
• Excellent organizational, analytical, and writing skills, with the ability to demonstrate critical thinking and problem-solving.
• Strong verbal and written communication skills, with excellent public speaking and presentation abilities.
• Knowledge of regulatory guidelines and Medicare Part A, MS-DRG, and/or APR-DRG payment methodologies.
• Strong proficiency in MS Office applications, including Word, PowerPoint, Excel, and Outlook.
• Excellent time management skills and the ability to handle multiple priorities effectively.

Consultant Salary Range: $70,000 – $150,000 per year Managing Consultant Salary Range: $100,000 – $230,000 per year We’re excited to offer a competitive sign‑on bonus to welcome exceptional talent. Candidate must be able to submit verification of his/her legal right to work in the U.S., without company sponsorship. #LI-REMOTE | #LI-JQ1 | PM22 About BRG BRG combines world-leading academic credentials with world-tested business expertise purpose-built for agility and connectivity, which sets us apart—and gets you ahead. At BRG, our top-tier professionals include specialist consultants, industry experts, renowned academics, and leading-edge data scientists. Together, they bring a diversity of proven real-world experience to economics, disputes, and investigations; corporate finance; and performance improvement services that address the most complex challenges for organizations across the globe. Our unique structure nurtures the interdisciplinary relationships that give us the edge, laying the groundwork for more informed insights and more original, incisive thinking from diverse perspectives that, when paired with our global reach and resources, make us uniquely capable to address our clients’ challenges. We get results because we know how to apply our thinking to your world. At BRG, we don’t just show you what’s possible. We’re built to help you make it happen. BRG is proud to be an Equal Opportunity Employer. Our hiring practices provide equal opportunity for employment without regard to race, religion, color, sex, gender, national origin, age, United States military veteran status, ancestry, sexual orientation, marital status, family structure, medical condition including genetic characteristics or information, veteran status, or mental or physical disability so long as the essential functions of the job can be performed with or without reasonable accommodation, or any other protected category under federal, state, or local law. Apply tot his job Apply To this Job