Clinical Document Improvement 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 Document Improvement Specialist based in the United States.

This role is essential in ensuring that inpatient clinical documentation accurately reflects the severity of illness, risk of mortality, and full scope of patient care. The position operates at the intersection of clinical care, coding, and health information management, working closely with physicians, nurses, and coding teams to improve documentation quality and compliance. It requires strong clinical judgment, attention to detail, and the ability to communicate effectively across multidisciplinary teams. The specialist actively reviews medical records, identifies gaps in documentation, and initiates clarifications to support accurate DRG assignment and reimbursement integrity. In addition, the role contributes to education, training, and continuous improvement initiatives within clinical documentation integrity programs. This is a remote opportunity suited for a healthcare professional who thrives in analytical, communication-heavy, and process-driven environments.

The Clinical Document Improvement Specialist is responsible for reviewing inpatient medical records and ensuring that documentation accurately captures clinical complexity, supports coding accuracy, and aligns with regulatory standards.

• Conduct concurrent and retrospective reviews of inpatient records to assess completeness and accuracy of documentation related to severity of illness and risk of mortality.
• Query physicians and care teams to clarify diagnoses, procedures, and clinical details through verbal and written communication.
• Collaborate with physicians, HIM coders, nurses, and case management teams to ensure accurate assignment of principal and secondary diagnoses.
• Identify documentation gaps and initiate improvement opportunities to support correct DRG assignment and quality reporting.
• Monitor CDI program metrics and reporting tools to track trends, identify issues, and support continuous improvement initiatives.
• Educate clinical staff on documentation best practices, compliance standards, and the impact of accurate clinical documentation.

This role requires strong clinical knowledge, CDI expertise, and the ability to collaborate effectively with multidisciplinary healthcare teams while maintaining accuracy and compliance in documentation practices.

• Associate degree in Health Information Management, Nursing, or related clinical field required; RHIT/RHIA, CCDS, or CDIP certification required depending on background.
• Minimum of 3 years of experience in clinical documentation improvement, utilization review, case management, or critical care.
• Licensed Registered Nurse (single-state or multi-state) or equivalent clinical licensure preferred; foreign medical graduates with CDI certification may be considered.
• Strong understanding of inpatient hospital operations, DRG assignment, ICD-10 coding principles, and documentation standards.
• Excellent communication skills with the ability to engage physicians and clinical staff in documentation clarification.
• Strong analytical and critical thinking skills with high attention to detail and accuracy.
• Ability to work independently in a remote environment while managing multiple concurrent reviews and deadlines.

• 100% remote work within the United States
• Comprehensive medical, dental, and vision insurance options
• Paid time off and holiday leave
• Retirement savings plan (401(k))
• Training and professional development opportunities in CDI and health information management
• Opportunity to work within a collaborative, multidisciplinary healthcare environment