Full Time / Long Term
PAY: Hourly

Clinical Documentation Improvement

Job Purpose
The Senior Consultant will be responsible for providing detailed assessments of clinical documentation practices, developing management plans to migrate our clients to a Best Practice environment, and implementing the recommended changes identified in these management plans.  Additionally, Senior Consultants have the opportunity to assist with pre-implementation, Implementation, and post implementation.

Viable candidates will possess a track record of success in Hospital Documentation Improvement.  Candidates should possess a minimum of an undergraduate degree.

Viable candidates should have significant subject matter expertise in documentation review, case management, coding in order to maximize realizable revenue, minimize denials, improve data for quality tracking and accelerate cash flow.

Position Objectives
Responsible for providing detailed assessments of documentation improvement, developing implementation plans to migrate our clients to a Best Practice environment, and implementing the recommended changes identified in these management plans.

We have multiple full-time positions nationwide which are on-site at client’s facilities. Positions are projected to be 6 months with possible long-term potential. Consultants are compensated for “hours worked”. Reimbursed travel/lodging expenses. Competitive compensation is commensurate with experience.

Extensive Travel is required.


  • Minimum 4 to 8 years’ experience in an acute care hospital or healthcare consulting environment


  • Bachelor’s degree from an accredited 4-year university


  • Holds one advanced credential (CCS/CCDS/CDIP/CCM/CMAC/CDMS/CMCN/COHN/CPUR/CPUM etc.)


  • Significant subject matter expertise in documentation improvement, case management & or coding processes to maximize realizable revenue, minimize denials, and accelerate cash flow.
  • Strong financial acumen; ability to develop budgets, forecast benefit, monitor for early warning signs and adapt the organization to achieve financial targets.
  • Proficient in Microsoft Office applications
  • Excellent verbal and written communication skills with ability to facilitate process change
  • Proven leadership ability
  • Able to function independently as an educator.
  • Able to function independently on Follow up reviews.


  • Instruct hospital personnel how to improve and implement accurate clinical documentation
  • Possess the ability to teach and mentor Clinical Documentation Improvement Specialists (CDIS).
  • Through education demonstrate the importance of a complete medical record that reflects an accurate picture of the severity of illness of patients.
  • Ability to act as resource for Clinical Documentation Improvement programs after the initial implementation.
  • Responsible for enhancing CMI by the measured success of the Clinical Documentation Program.
  • Prepares status reports for the Manager and Director Clinical Documentation Improvement.
  • Responsible for utilizing a tracking tool to capture activity the of Clinical Documentation Improvement program.
  • Obtains a strong background in MS-DRG’s, ICD-10 codes, coding guidelines and coding clinics. 
  • Able to develop and enhance Clinical Documentation Improvement educational material.
  • Educate physicians to understand the importance of the CDIS role and to partner with the physician to improve clinical documentation and furthermore improving the physician’s “report card”
  • Functions as Project Lead.
  • Oversees Weekly Status reports.
  • Maintains weekly Financial Benefit reports.
  • Conducts weekly/monthly client follow up calls.
  • Assembles Steering Committee Reports.
  • Participates in Pre-implementing planning.
  • Help client to be instrumental in improving outcomes of Recovery Audit Contractor Program (RAC) audits.
  • Ability to track and trend Clinical Documentation Improvement successes.
  • Provides CDI Team, physicians, administration and Steering Committee ongoing feedback.
  • Understands and supports CDIdocumentation strategies.


  • Accepted file types: pdf, doc, jpg, docx.