Clinical Documentation Specialist I 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 I based in the United States.

In this role, you will play a key part in ensuring the accuracy, completeness, and integrity of clinical documentation across patient records. You will collaborate closely with physicians, nurses, and clinical teams to clarify documentation, support proper coding, and ensure compliance with established healthcare standards. Working in a remote healthcare environment, you will review inpatient and outpatient records to validate diagnoses, procedures, and risk indicators such as severity of illness and mortality risk. Your expertise will directly impact reimbursement accuracy, quality reporting, and overall patient care documentation quality. This position requires strong clinical judgment, attention to detail, and the ability to communicate effectively with providers. You will also contribute to education efforts that help improve documentation practices across the organization.

• Review inpatient and outpatient medical records to ensure accurate, complete, and compliant clinical documentation.
• Assign and validate principal diagnoses, secondary diagnoses, and procedures to support appropriate DRG, APC, and HCC assignment.
• Query physicians and clinical providers to clarify documentation and ensure specificity, accuracy, and present-on-admission status.
• Support compliance with coding and documentation standards, including ICD-10-CM, CPT, HCPCS, and payer guidelines.
• Maintain detailed records of reviews, queries, and responses using CDI software systems.
• Monitor and meet daily productivity targets for record reviews and provider queries.
• Apply clinical knowledge to assess severity of illness, risk of mortality, and overall patient complexity.
• Participate in provider education initiatives to improve documentation quality and coding accuracy.
• Assist team members and leadership with workload support, process guidance, and coverage determinations when needed.
• Contribute to continuous improvement of CDI workflows and best practices.
• Pursue ongoing professional development, including CEU requirements and certification advancement (such as ACDIS certification).

• High School Diploma or GED required.
• Minimum of 5 years of experience as a clinical nurse, inpatient/outpatient coder, or 2 years of experience as a Clinical Documentation Integrity Specialist.
• Strong understanding of clinical documentation practices in inpatient and outpatient settings.
• Proficiency with CDI software systems and reporting tools.
• Knowledge of medical coding systems including ICD-10-CM, CPT, HCPCS, and HCC methodologies.
• Ability to analyze medical records and translate clinical information into accurate coded data.
• Strong communication skills with the ability to educate and query physicians and clinical staff effectively.
• Excellent attention to detail, organizational skills, and ability to meet productivity targets.
• Strong clinical background in areas such as Med-Surg, ICU, or Emergency Care preferred.
• Associate’s degree in a healthcare-related field preferred.
• Registered Nurse (RN) license preferred.
• Certification as CCDS or CCDS-O preferred or willingness to obtain within one year.
• Ability to work independently in a remote environment while managing multiple priorities.

• Remote work arrangement with structured weekday schedule (8:00 a.m. – 5:00 p.m.).
• Opportunity to work in a high-impact clinical role supporting quality care and accurate reimbursement.
• Professional development support, including CEU requirements and certification advancement.
• Exposure to advanced Clinical Documentation Integrity (CDI) systems and workflows.
• Career growth opportunities within clinical informatics, coding, and healthcare administration.
• Collaborative environment working closely with physicians and multidisciplinary clinical teams.
• Comprehensive healthcare benefits and standard employee wellness programs (subject to eligibility).
• Opportunity to contribute directly to improving patient record accuracy and healthcare quality outcomes.