Remote | Clinical Documentation Review Specialist — $60–$90/hour

24-Mag • New York, NY

15h • Remote

About The Position

We are sharing a specialised part-time consulting opportunity for professionals experienced in clinical documentation, medical scribing, CDI workflows, encounter notes, discharge summaries, EHR documentation, and structured healthcare documentation review. This role supports current and upcoming remote consulting opportunities focused on structured clinical documentation review, encounter note analysis, transitions-of-care documentation, CDI query assessment, EHR workflow review, and high-quality project execution. Selected professionals will apply their clinical documentation expertise to review realistic healthcare scenarios, evaluate documentation requirements, prepare structured written outputs, and support accurate, evidence-based clinical documentation tasks.

Requirements

• 2+ years of experience as a medical scribe, CDI specialist, RN, NP, PA, clinical documentation specialist, medical records reviewer, or similar documentation-heavy healthcare professional
• Experience with one or more areas such as SOAP note preparation, H&P documentation, progress notes, discharge summaries, CDI query practice, medication reconciliation, or EHR documentation workflows
• Familiarity with EHR systems such as Epic, Cerner, Meditech, Athenahealth, eClinicalWorks, or similar healthcare documentation platforms
• Comfort reading and preparing clinical artifacts such as SOAP notes, H&Ps, progress notes, discharge summaries, CDI queries, encounter summaries, and medication reconciliation records
• Strong written communication skills and ability to explain clinical documentation reasoning clearly
• Ability to follow structured instructions and produce evidence-based work

Nice To Haves

• RN, NP, PA, RHIA, RHIT, CCS, CCDS, CDIP, medical scribe certification, or equivalent clinical documentation background
• Experience with CDI query development, discharge summaries, medication reconciliation, encounter note review, or transitions-of-care documentation
• Familiarity with Epic, Cerner, Meditech, Athenahealth, eClinicalWorks, or other EHR systems
• Experience preparing or reviewing SOAP notes, H&Ps, progress notes, discharge summaries, CDI queries, or clinical documentation packets
• Strong attention to detail in documentation-heavy healthcare environments

Responsibilities

• Review clinical documentation scenarios involving SOAP notes, H&Ps, progress notes, encounter summaries, and source-supported clinical findings
• Evaluate encounter documentation against required elements, source materials, clinical note structure, and documentation standards
• Support structured review of patient history, exam findings, assessment details, plans, and progress documentation
• Identify missing elements, unsupported findings, documentation gaps, and expected clinical note outcomes
• Review discharge summaries, transitions-of-care materials, medication reconciliation records, and required-field documentation
• Evaluate discharge documentation against source materials, medication lists, care instructions, follow-up requirements, and documentation criteria
• Support structured review of clinical summaries, medication reconciliation details, handoff materials, and continuity-of-care documentation
• Prepare clear written explanations for documentation decisions based on provided materials and verifiable criteria
• Review CDI query scenarios involving documentation gaps, query framing, rule-based triggers, and clinical clarification workflows
• Evaluate CDI queries against documented facts, required wording standards, clinical context, and structured review criteria
• Support structured review of EHR documentation workflows using systems such as Epic, Cerner, or similar platforms
• Maintain accuracy, consistency, and professional judgment across submitted work

Benefits

• Competitive hourly compensation
• Flexible scheduling
• Part-time commitment
• Weekly payments
• Projects may be extended, shortened, or adjusted depending on scope and performance

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: Associate degree