Clinical Documentation Specialist

Accountabilities

• • Review patient medical records to improve the overall quality, accuracy, and completeness of clinical documentation.
  • Assess 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.