About the Role
We are seeking a skilled Clinical Documentation Specialist to join our remote team. You will work under limited direction to improve the overall quality and completeness of clinical documentation in the legal medical record — playing a critical role in ensuring accurate reimbursement, optimizing Severity of Illness (SOI) and Risk of Mortality (ROM) levels, and supporting clinical coding and billing integrity.
Key Responsibilities
- Improve documentation quality through concurrent inpatient medical record review
- Collaborate with physicians, HIM staff, and coding teams to ensure accurate reimbursement and appropriate SOI/ROM levels
- Monitor inpatient records concurrently — reviewing diagnoses, treatments, and follow-up entries for accuracy
- Submit physician queries to resolve documentation gaps and support compliant coding and billing
- Educate physicians on documentation requirements, guideline changes, and reimbursement opportunities
- Apply knowledge of medical terminology and clinical procedures to identify documentation improvement opportunities
Qualifications
At least one of the following credentials:
▪ Active RN License (any U.S. state)
▪ RHIA | RHIT | CCS
All of the following are required:
▪ Minimum 1 year of acute care (inpatient) concurrent CDI experience
▪ Active CCDS (ACDIS) or CDIP (AHIMA) credential
▪ Experience with concurrent inpatient record review and physician queries
▪ Strong knowledge of ICD-10-CM/PCS, DRG methodology, and SOI/ROM measures
▪ Proficiency with EHR systems and CDI software tools