Clinical Documentation Integrity (CDI) Specialist

To qualify you must work regularly in a professional inpatient CDI or coding role — hospital CDI (specialist or leadership), inpatient DRG coding/auditing, or clinical-documentation denial management — with 2+ years of experience under ICD-10-CM/PCS and the MS-DRG system.

Clinical documentation knowledge we require

Coding & the pre-bill cycle

• ICD-10-CM/PCS assignment, POA reporting, and the inpatient DRG assignment and reimbursement cycle

• Concurrent and retrospective (pre-bill) review, DRG reconciliation (working vs. final), and tie-out of coded diagnoses to source documentation in the record

Judgment & evaluation

• CC/MCC impact and DRG movement; when a diagnosis does or doesn't change the DRG, severity of illness, or risk of mortality

• Code changes and their coupled effects (principal-diagnosis sequencing, DRG shift, dollar and quality impact)

Clinical standards & criteria

• Applying published clinical criteria to the record — AKI staging (KDIGO), sepsis, respiratory failure, malnutrition, CKD staging — and UHDDS reporting rules

• Distinguishing a clinically supported diagnosis from an unsupported or templated/copy-forward one; clinical validation

Query & compliance discipline

• AHIMA/ACDIS-compliant, non-leading query construction; when a query is required versus when specificity is already provider-documented

• The bright line: indicators justify a query, never a code — never add, delete, or change a provider-documented diagnosis without a provider response

Documentation & evidence

• Query vs. CDI-review vs. note standards, hold/pending mechanics, review-ready completeness

• Evidence provenance: a lab value, document, baseline, or DRG figure is only valid if it is actually in the record and produced by the grouper, not asserted

Tools

• Comfort in professional CAC/CDI software — computer-assisted coding and CDI workflow platforms (e.g., Dolbey Fusion, 3M 360 Encompass, Nuance/Optum360), DRG groupers, and EHR systems (e.g., Epic)

What you'll do

• Review AI-agent attempts at realistic CDI/coding tasks and judge whether each disposition is correct and adequately supported by the record

• Confirm work is actually completed and recorded — codes changed, queries sent (not left in draft), holds placed, DRG recomputed, notes and CDI reviews filed — not just described

• Catch fabricated or overstated work: cited labs, documents, or prior encounters that don't exist, a claimed provider response that never came, DRG or dollar figures not produced by the grouper

• Judge completeness and whether the right action was applied to the right chart — code fix vs. query vs. clinical-validation query vs. leave-alone — and require verify-before-finalize

• Write clear, specific agree/disagree rationales on each attempt

Requirements

• 2+ years of professional experience in one or more of: inpatient hospital CDI (specialist or leadership), inpatient DRG coding/auditing, or clinical-documentation denial management

• Current or recent hands-on work under ICD-10-CM/PCS and MS-DRGs

• Reflexive professional judgment; can spot an unsupported diagnosis, a leading query, a missed CC/MCC, or a rubber-stamped account on sight

• CCDS, CDIP, CCS, RHIA/RHIT, or RN with CDI experience (or equivalent); hospital, coding, or HIM background

• Comfort working inside CAC/CDI software and reading the full clinical record — H&Ps, consults, progress notes, discharge summaries, labs, and flowsheets

We consider all qualified applicants without regard to legally protected characteristics and provide reasonable accommodations upon request.

Contract and Payment Terms

• You will be engaged as an independent contractor.
• This is a fully remote role that can be completed on your own schedule.
• Projects can be extended, shortened, or concluded early depending on needs and performance.
• Your work at Mercor will not involve access to confidential or proprietary information from any employer, client, or institution.
• Payments are weekly on Stripe or Wise based on services rendered.
• Please note: We are unable to support H1-B or STEM OPT candidates at this time.

About Mercor

Mercor partners with leading AI labs and enterprises to train frontier models using human expertise. You will work on projects that focus on training and enhancing AI systems. You will be paid competitively, collaborate with leading researchers, and help shape the next generation of AI systems in your area of expertise.