Clinical Documentation Specialist

The Clinical Documentation Specialist position is a remote, per diem opportunity based in the United States. This role focuses on improving the quality, accuracy, and completeness of provider-based clinical documentation.

About the Role

You will review patient records to help ensure documentation accurately reflects patients' severity of illness and the level of services provided. You will collaborate with physicians, coding professionals, and other members of the patient care team to support comprehensive and accurate patient documentation. Additionally, you will identify documentation opportunities and assist providers in clarifying clinical information when appropriate and compliant. You will also formulate, monitor, and respond to documentation clarification requests in accordance with applicable requirements and best practices. You will develop and deliver clinical documentation improvement education and guidance to providers to promote consistent documentation practices that support accurate clinical representation and effective health information management.

Responsibilities

• Review patient medical records to improve the overall quality, accuracy, and completeness of clinical documentation.
• Absess documentation to ensure it appropriately reflects the patient’s severity of illness and the level of services rendered.
• Collaborate with providers, coders, and other patient care team members to support comprehensive and accurate patient documentation.
• Identify documentation opportunities and assist providers in clarifying clinical information when appropriate and compliant.
• Formulate, monitor, and respond to documentation clarification requests in accordance with applicable requirements and best practices.
• Develop and deliver clinical documentation improvement education and guidance to providers.
• Promote consistent documentation practices that support accurate clinical representation and effective health information management.
• Work independently in a remote environment while maintaining accuracy, responsiveness, and adherence to established processes.

Requirements

• Associate degree in Health Information Management or a related field.
• 1–2 years of inpatient coding experience.
• Active Registered Nurse (RN) license or a relevant certification such as RHIA, RHIT, CCS, CDIP, or CCDS.
• Experience with acute-care inpatient coding or clinical documentation improvement is preferred.
• Bachelor’s degree in Nursing, Health Information Management, or a related field is preferred.
• Strong understanding of clinical documentation, inpatient coding principles, and health information management practices.
• Excellent analytical and critical-thinking skills, with the ability to review clinical records and identify documentation opportunities.
• Strong written and verbal communication skills for working effectively with providers, coders, and multidisciplinary teams.
• High attention to detail, accuracy, organization, and commitment to compliant documentation practices.
• Ability to work effectively and independently in a remote setting.

Benefits

• Remote work: Fully remote position within the United States, subject to state eligibility requirements.
• Flexible per diem schedule: Per diem employment with daytime shifts and no guaranteed weekly hours.
• Salary range: $41,600–$134,680, depending on applicable factors.
• 401(k) retirement plan: Available to eligible per diem employees; no company match is provided for per diem status.
• Employee Assistance Program: Access to support resources for personal and professional needs.
• Employee discounts: Access to available employee discount programs.
• Flexible benefits: Programs designed to support family needs, financial wellbeing, and personal wellbeing.
• State eligibility: Remote employment is currently unavailable to residents of California, Colorado, Hawaii, Massachusetts, New Jersey, New York, Oregon, Pennsylvania, Washington, and U.S. territories due to legal, tax, and regulatory requirements.