Clinical Documentation Specialist Jobs

About The Position

Requirements

• Active Registered Nurse (RN) license
• Minimum of 5 years of acute Inpatient Clinical documentation Improvement (CDI) experience within a large tertiary or trauma hospital environment
• Experience working within electronic health record systems
• Strong knowledge of inpatient CDI practices, physician documentation, ICD-10-CM/PCS coding guidelines, DRG assignment, and compliant query practices
• Excellent clinical judgment, analytical thinking, problem-solving, and critical thinking skills
• Strong written and verbal communication skills with the ability to effectively educate and collaborate with physicians and interdisciplinary healthcare teams
• Ability to work independently while managing multiple priorities in a fully remote environment

Nice To Haves

• CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) certification
• Experience supporting multiple client environments or consulting engagements
• Familiarity with clinical validation principles and payer documentation requirements
• Experience collaborating with inpatient coding, quality, and revenue cycle teams to improve documentation integrity and reimbursement outcomes

Responsibilities

• Review inpatient medical records to evaluate the accuracy, completeness, and clinical integrity of physician documentation
• Identify documentation improvement opportunities and issue concise, compliant provider queries in accordance with AHIMA and ACDIS best practices
• Collaborate with physicians, coding professionals, and clinical staff to improve documentation quality and coding accuracy
• Analyze clinical documentation, laboratory results, medications, physician orders, diagnostic testing, and other clinical information to validate reportable diagnoses and procedures
• Perform concurrent, continued stay, and retrospective chart reviews while maintaining accurate workflow documentation and meeting client-specific productivity and quality expectations
• Monitor query follow-up, reconciliation, and escalation activities in accordance with client workflows and turnaround expectations
• Apply Official ICD-10-CM/PCS Coding Guidelines, Coding Clinic guidance, and client-specific clinical validity criteria throughout the documentation review process
• Educate providers and clinical staff on documentation best practices that support accurate clinical representation and compliant reimbursement
• Maintain a strong understanding of inpatient coding, DRG assignment, clinical documentation improvement, and healthcare regulations
• Deliver high-quality work while collaborating effectively with internal CDI, coding, quality, and client teams in a fully remote environment

Benefits

• Comprehensive medical, dental, and vision insurance
• 401(k) with company match
• Generous paid time off plus eight paid holidays
• 100% remote work environment with company-provided equipment
• Professional development, continuing education, leadership training, and internal career growth opportunities
• Complimentary annual CEUs
• Access to advanced coding education and learning resources
• Employee wellness resources and discount programs
• Referral bonus opportunities
• White glove onboarding designed to set you up for success