Clinical Documentation Improvement Specialist

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

📋 Description

• Assess and review medical record documentation for completeness, accuracy, and adherence to compliance standards.

• Partner with physicians, nurses, and coding specialists to ensure proper clinical documentation.

• Detect opportunities for enhancing documentation to aid coding precision, reimbursement, and clinical outcomes.

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

• Develop compliant and clinically sound queries directed to physicians.

⛳️ Requirements

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

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

• Certification as a Registered Nurse (RN) is mandatory.

• CCDS/CDIP certification is preferred but not essential.

• Familiarity with ICD-10-CM, MS-DRGs, coding guidelines, 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 platforms (MS Teams, Zoom, etc.).

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

🏝️ Benefits

• Comprehensive benefits package.

• Paid Time Off (PTO).

• Competitive salary.

• A collaborative, mission-focused team environment.

• Opportunities for continuous learning, education, and professional advancement.

• Leadership that appreciates your expertise and contributions.

• Fully remote work capability.