Clinical Documentation Specialist

Accountabilities

• Conduct comprehensive clinical documentation reviews and collaborate with healthcare stakeholders to ensure accurate, complete, and compliant patient records.
• Identify documentation gaps, support coding accuracy, and improve clinical data quality.
• Perform daily concurrent reviews of inpatient medical records to identify opportunities for documentation clarification and improvement.
• Evaluate clinical documentation to ensure it accurately represents patient conditions, severity of illness, and risk of mortality.
• Collaborate with physicians, coders, coding educators, auditors, case managers, and quality teams to improve documentation practices.
• Initiate compliant physician queries when documentation is incomplete, unclear, conflicting, or requires clarification.
• Follow established clinical documentation improvement guidelines and regulatory standards to maintain compliance.
• Communicate workload needs and review volume concerns to support efficient assignment management across the CDI team.
• Utilize electronic health record systems, CDI platforms, and coding tools to support effective documentation review processes.

Requirements

• Experienced healthcare professional with strong clinical knowledge, documentation expertise, and effective communication skills.
• 4+ years of experience providing direct patient care in inpatient settings, including acute care, critical care, emergency department, or medical-surgical environments.
• 2+ years of prior Clinical Documentation Improvement (CDI) experience.
• Familiarity with encoder tools, DRG assignment processes, and clinical coding methodologies.
• Strong knowledge of official coding guidelines, coding clinics, medical terminology, anatomy, physiology, microbiology, and disease processes.
• Experience with EHR systems, CDI software platforms, and coding technologies.
• Strong critical thinking, analytical abilities, and problem-solving skills.
• Excellent interpersonal and communication skills, including the ability to discuss complex documentation topics with physicians.
• CCDS or CDIP certification preferred.
• Additional experience in coding, case management, utilization review, or inpatient acute care environments is a plus.

Benefits

• Competitive annual salary range of $61,000 - $101,000, depending on skills, experience, training, certifications, and organizational needs.
• Remote work opportunity available across the United States.
• Comprehensive medical, prescription, dental, and vision insurance coverage.
• Paid holidays and personal/family sick time benefits.
• Potential eligibility for discretionary incentive bonus programs.
• Parental leave and adoption assistance.
• 401(k) retirement plan.
• Basic and supplemental life insurance options.
• Health Savings Account and Flexible Spending Account options.
• Short-term and long-term disability coverage.
• Student loan repayment support.
• Tuition reimbursement and ongoing professional development opportunities.
• Additional workplace support programs, including emergency childcare assistance and mobility benefits.