Clinical Documentation Improvement Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Assess and analyze medical record documentation to ensure it is complete, accurate, and adheres to compliance standards.

• Work in partnership with physicians, nurses, and coding specialists to guarantee appropriate clinical documentation.

• Identify areas for improvement in documentation to enhance coding accuracy, reimbursement processes, and clinical outcomes.

• Review medical records to confirm that documentation supports high-quality care and appropriate reimbursement.

• Develop compliant and clinically appropriate queries for physicians.

⛳️ Requirements

• Experience: Minimum of 2 years in clinical documentation improvement (CDI).

• Certification: Must hold a Registered Nurse (RN) license.

• Familiarity with ICD-10-CM, MS-DRGs, coding guidelines, and compliance standards.

• Strong communication, critical thinking, and organizational skills are essential.

• Proficient in using MS Office, email, VPNs, virtual machines, two-factor authentication, and video conferencing platforms (such as MS Teams, Zoom, etc.).

• Experience with 3M and Epic is preferred but not mandatory.

🏝️ Benefits

• A collaborative, mission-driven team atmosphere.

• Opportunities for ongoing learning, education, and professional development.

• Leadership that appreciates your expertise and contributions.