Consultant – Clinical Documentation Integrity (CDI) – Healthcare

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.

The 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 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.

Willing to travel consistently (50% - 75%), depending on project requirements and client expectations, is required for this position.

Responsibilities

Apply strong understanding of clinical documentation and care delivery workflows, translating clinical practice into accurate documentation that supports coding, quality reporting, and case mix integrity across inpatient and outpatient/physician settings.

Conduct comprehensive inpatient medical record reviews for identified payer populations upon admission and throughout hospitalization.

• Serve as an educational resource to client CDI teams, delivering classroom education, hands‑on teaching, and ongoing mentoring.
• Develop and deliver training to physicians, nurses, coding professionals, and ancillary staff on documentation best practices.
• Analyze clinical information to identify gaps in documentation related to SOI, POA, MS‑DRG, APR‑DRG, PSI, and quality measures.
• Formulate credible and compliant documentation clarifications.
• Work collaboratively with coding teams to ensure accuracy and completeness of documentation and diagnoses.
• Support clinical staff in understanding documentation needs through frequent interaction and coaching.
• Provide high‑quality input for client deliverables and contribute to expert reports.
• Provide interim CDS support as needed.
• Assist in developing CDI and HIM training tools, methodologies, and education materials.

Qualifications

• Bachelor’s degree in a related discipline preferred (RN, BSN, RHIA, RHIT, HIM, or similar).
• 2-5 years of consulting experience with an RN or clinical background is required. RNs without consulting experience will not be considered.
• Experience working in an academic medical center preferred.
• Ideal candidates have worked in clinical operations, quality, PI, clinical transformation, or similar advisory areas.
• Demonstrated consulting skill set, including strong critical thinking, communication, presentation, and analytical capabilities.
• Enthusiasm and aptitude for teaching and mentoring, with the ability to deliver education to clinicians, coders, and internal teams.
• Current CCDS, CCS, or CDIP certification, or willingness and ability to obtain one, is required.
• RHIA, RHIT, CRC, CPC, or other coding credentials are highly preferred.
• Strong understanding of DRG, MS‑DRG, APR‑DRG, and HCC methodologies.
• Experience using EMRs such as Epic, Meditech, Cerner, 3M 360, etc.
• Ability to translate complex clinical, documentation, and coding concepts into clear, actionable education.
• Strong proficiency in MS Office (Word, Power Point, Excel, Outlook).
• Excellent time management skills and the ability to balance multiple priorities effectively.
• Desire to grow within the CDI consulting space while cross‑collaborating with other IHS service lines is necessary.

A self‑starter with the ability to work effectively in the ambiguous, rapidly evolving consulting environment.

Salary Range: $90,000 – $135,000 per year

Job title and compensation will be determined based on qualifications and experience.

Candidate must be able to submit verification of his/her legal right to work in the United States, without company sponsorship.

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.

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