Clinical Documentation Specialist in United States at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Clinical Documentation Specialist based in the United States.

The Clinical Documentation Specialist plays a critical role in improving healthcare documentation accuracy, compliance, and quality outcomes through detailed clinical record reviews. This position works closely with physicians, coding teams, case managers, and quality professionals to ensure patient records accurately reflect clinical complexity, severity of illness, and risk of mortality. The role combines clinical expertise, analytical thinking, and regulatory knowledge to identify documentation improvement opportunities and support accurate coding practices. The successful candidate will contribute to healthcare quality initiatives while working in a collaborative, remote environment. This opportunity is ideal for a healthcare professional who enjoys problem-solving, interdisciplinary collaboration, and making a measurable impact on clinical data integrity.

The Clinical Documentation Specialist is responsible for conducting comprehensive clinical documentation reviews and collaborating with healthcare stakeholders to ensure accurate, complete, and compliant patient records. The role focuses on identifying documentation gaps, supporting coding accuracy, and improving clinical data quality.

• Perform daily concurrent reviews of inpatient medical records to identify opportunities for documentation clarification and improvement.
• Evaluate clinical documentation to ensure it accurately represents patient conditions, severity of illness, and risk of mortality.
• Collaborate with physicians, coders, coding educators, auditors, case managers, and quality teams to improve documentation practices.
• Conduct initial reviews of patient admissions, assign working DRGs, and maintain accurate CDI software documentation.
• Update working DRG assignments based on supporting clinical documentation and physician query responses.
• Initiate compliant physician queries when documentation is incomplete, unclear, conflicting, or requires clarification.
• Follow established clinical documentation improvement guidelines and regulatory standards to maintain compliance.
• Communicate workload needs and review volume concerns to support efficient assignment management across the CDI team.
• Utilize electronic health record systems, CDI platforms, and coding tools to support effective documentation review processes.

The ideal candidate is an experienced healthcare professional with strong clinical knowledge, documentation expertise, and the ability to communicate effectively with medical teams. This role requires a combination of direct patient care experience, CDI knowledge, and analytical problem-solving skills.

• Bachelor’s degree required.
• Active professional qualification as an RN, MD, or equivalent medical degree (MBBS).
• 4+ years of experience providing direct patient care in inpatient settings, including acute care, critical care, emergency department, or medical-surgical environments.
• 2+ years of prior Clinical Documentation Improvement (CDI) experience.
• Familiarity with encoder tools, DRG assignment processes, and clinical coding methodologies.
• Strong knowledge of official coding guidelines, coding clinics, medical terminology, anatomy, physiology, microbiology, and disease processes.
• Experience with EHR systems, CDI software platforms, and coding technologies.
• Strong critical thinking, analytical abilities, and problem-solving skills.
• Excellent interpersonal and communication skills, including the ability to discuss complex documentation topics with physicians.
• CCDS or CDIP certification preferred.
• Additional experience in coding, case management, utilization review, or inpatient acute care environments is a plus.

• Competitive annual salary range of $61,000 – $101,000, depending on skills, experience, training, certifications, and organizational needs.
• Remote work opportunity available across the United States.
• Comprehensive medical, prescription, dental, and vision insurance coverage.
• Paid holidays and personal/family sick time benefits.
• Potential eligibility for discretionary incentive bonus programs.
• Parental leave and adoption assistance.
• 401(k) retirement plan.
• Basic and supplemental life insurance options.
• Health Savings Account and Flexible Spending Account options.
• Short-term and long-term disability coverage.
• Student loan repayment support.
• Tuition reimbursement and ongoing professional development opportunities.
• Skills training, certification support, employee referral programs, and community engagement initiatives.
• Additional workplace support programs, including emergency childcare assistance and mobility benefits.