Clinical Documentation Improvement Specialist

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

📋 Description

• Assess and analyze medical record documentation for completeness, accuracy, and compliance.

• Work in partnership with physicians, nurses, and coding experts to guarantee proper clinical documentation.

• Recognize areas for documentation enhancement to bolster coding accuracy, reimbursement, and clinical results.

• Examine medical records to confirm that documentation reflects quality care and appropriate reimbursement.

• Develop compliant and clinically appropriate queries for physicians.

⛳️ Requirements

• At least 2 years of experience in inpatient clinical documentation improvement (CDI).

• A minimum of 2 years of bedside nursing experience in an acute care environment (ICU, Med/Surg, ED, etc.).

• A valid Registered Nurse (RN) certification is required.

• CCDS/CDIP certification is preferred but not mandatory.

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

• Strong communication, critical thinking, and organizational abilities.

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

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

🏝️ Benefits

• Comprehensive benefits package.

• Paid time off (PTO).

• Competitive salary.

• Supportive, mission-driven team atmosphere.

• Opportunities for ongoing education and professional development.

• Leadership that appreciates your expertise and contributions.

• Fully remote work options.