Pediatric CDI Specialist (Part-Time Contract)
Pediatric CDI Specialist Position Type: Contract Estimated Hours: 20–32 hours per week Start Date: ASAP Initial Duration: 6 months Position Overview We are seeking an experienced Pediatric Clinical Documentation Integrity Specialist to support inpatient pediatric CDI initiatives. This role will focus on concurrent medical record review, documentation improvement, physician query development, coding accuracy, and collaboration with clinical, coding, quality, and compliance teams. The ideal candidate will bring a strong pediatric clinical background, hands-on CDI experience, and deep understanding of pediatric disease processes, documentation requirements, and coding/regulatory standards.
Required Qualifications
Candidates must have a clinical background as one of the following:
- Registered Nurse
- RHIA, RHIT, CCS, or equivalent coding credential
- Foreign Medical Graduate with U.S. inpatient documentation experience
Additional requirements include:
- Bachelor’s degree in Nursing, Health Information Management, or related field
- 2–3+ years of Clinical Documentation Integrity experience with a pediatric inpatient focus
- 3–5+ years of direct pediatric clinical experience
- Pediatric acute care experience
- PICU and/or NICU experience strongly preferred or required
Pediatric Clinical Expertise Candidates must have strong knowledge of pediatric anatomy, physiology, developmental variations, pediatric disease processes, and age-specific clinical indicators. Experience supporting documentation for the following areas is required or strongly preferred:
- Neonatology and prematurity-related conditions
- Pediatric respiratory conditions, including respiratory distress vs. respiratory failure
- Pediatric sepsis definitions and criteria
- Pediatric acute kidney injury
- Growth failure and pediatric malnutrition
- Congenital and genetic conditions
- Neurologic conditions, including seizures, encephalopathy, and altered mental status
- Technology-dependent pediatric patients, including tracheostomy, G-tube, and VP shunt patients
Key Responsibilities
- Perform concurrent inpatient review of pediatric medical records
- Identify documentation opportunities impacting Severity of Illness, Risk of Mortality, and APR-DRG or MS-DRG assignment
- Initiate and follow up on clinically appropriate and compliant physician queries
- Ensure documentation accurately reflects diagnosis specificity, present-on-admission status, complications, and comorbidities
- Collaborate with coding, quality, compliance, pediatric providers, and pediatric subspecialists
- Participate in provider education related to pediatric documentation improvement
- Support compliant CDI processes in alignment with organizational, coding, and regulatory standards
Coding & Regulatory Knowledge Candidates should have advanced knowledge of:
- ICD-10-CM pediatric-specific coding rules
- ICD-10-PCS, when applicable for pediatric cases
- APR-DRGs and/or MS-DRGs
- Birth weight and gestational age documentation
- Newborn vs. pediatric encounter distinctions
- Congenital vs. acquired diagnoses
- AHIMA and ACDIS CDI and query compliance guidelines
Technology & Systems Experience
- Experience using electronic health records, preferably Epic
- Epic Pediatric and Neonatal module experience preferred
- Experience with CDI software preferred, including 3M 360 Encompass or Optum CDI
- Ability to work effectively in remote or hybrid CDI environments
Communication & Professional Skills
- Strong written communication skills for physician queries and clinical rationale documentation
- Ability to communicate effectively with pediatric hospitalists, intensivists, neonatologists, and pediatric subspecialists
- Demonstrated ability to work independently and manage concurrent workloads
- Strong attention to detail, clinical judgment, and compliance awareness
Preferred Certifications
- CCDS — Certified Clinical Documentation Specialist
- CDIP — Certified Documentation Integrity Practitioner
- Pediatric-specific CDI certification, if applicable