Clinical Documentation Integrity Specialist

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

📋 Description

• Assess and analyze medical record documentation for thoroughness, correctness, and compliance.

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

• Spot areas for enhancement in documentation to bolster coding precision, reimbursement, and clinical outcomes.

• Evaluate medical records to confirm that documentation reflects quality care and proper reimbursement.

• Develop compliant and clinically valid physician queries.

⛳️ 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.).

• 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 regulations.

• Strong communication, critical thinking, and organizational skills.

• 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 required.

🏝️ Benefits

• Comprehensive benefits package.

• Paid Time Off (PTO).

• Competitive compensation.

• Supportive, mission-focused team environment.

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

• Leadership that appreciates your expertise and contributions.