Clinical Documentation Specialist I

Accountabilities:

Educate physicians, nursing staff, allied health practitioners, and other members of the patient-care team on clinical documentation regulations, standards, and best practices.
Communicate regularly with physicians and healthcare providers to promote accurate, complete, and clinically appropriate medical documentation.
Conduct concurrent medical record reviews to assess documentation completeness, accuracy, and compliance with established clinical and quality guidelines.
Identify documentation gaps, inconsistencies, and opportunities for improvement related to severity of illness (SOI), risk of mortality (ROM), and quality indicators.
Initiate and develop clinically supported documentation clarification requests for inpatient cases, ensuring that identified opportunities are accurately presented to the appropriate clinical professionals.
Prepare and maintain clinical documentation improvement (CDI) severity worksheets and formulate clear, clinically credible clarification requests.
Conduct timely follow-up reviews of active cases, prioritizing records requiring documentation clarification and ensuring outstanding requests are addressed.
Collaborate with physicians and other clinical staff to resolve documentation discrepancies, coding questions, and clinical record inconsistencies.
Monitor physician responses to valid documentation clarification requests, maintaining a response rate of at least 95%.
Enter and maintain accurate information within CDI software systems to support reliable reporting, performance measurement, and reconciliation processes.
Transcribe documentation clarifications when appropriate to ensure medical records accurately reflect clinical findings and treatment decisions.
Participate in departmental meetings, communicate outstanding issues, share feedback, and identify opportunities for additional clinical documentation education.
Support continuous improvements in documentation compliance, clinical data integrity, and overall healthcare quality.
Perform additional duties as assigned.
Requirements:
At least 5 years of acute care nursing or clinical experience, with specific experience in medical-surgical units, intensive care, post-acute care, or emergency departments.
An active and applicable professional clinical credential is required. Accepted qualifications include Registered Nurse (RN), Physician Assistant (PA), Medical Doctor (MD), Certified Registered Nurse Practitioner (CRNP), Adult Acute Care Nurse Practitioner (ACNPC), or Educational Commission for Foreign Medical Graduates (ECFMG).
Bachelor's or Master's degree in Nursing is preferred.
Educational backgrounds in Health Services Administration, Business Administration, Systems Performance Engineering, Industrial Engineering, or Public Health are also relevant.
Previous experience as a Clinical Documentation Specialist is preferred.
Certification as a Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) is an advantage.
Strong knowledge of pathophysiology, disease processes, medical treatments, and clinical terminology.
Understanding of clinical documentation requirements, including the appropriate identification and representation of patient conditions and medical procedures.
Familiarity with medical coding principles and healthcare quality guidelines is preferred.
Excellent interpersonal, written, and verbal communication skills, with the ability to establish productive working relationships with physicians and multidisciplinary healthcare teams.
Strong analytical, critical-thinking, problem-solving, and deductive-reasoning abilities, particularly when reviewing complex clinical information and identifying documentation opportunities.
Excellent organizational and prioritization skills, with the ability to manage multiple concurrent cases, follow-up activities, and competing deadlines.
Strong computer and keyboarding skills, including the ability to navigate multiple software applications simultaneously and maintain accurate electronic records.
Ability to organize, interpret, and present complex clinical information clearly and concisely.
Dependable, self-motivated, adaptable, and professional, with the ability to work independently and maintain consistent performance in a remote environment.
Willingness and ability to continuously develop clinical documentation expertise and stay informed about evolving industry standards and regulatory requirements.
Benefits:
Competitive compensation: Annual salary ranging from $66,830.40 to $124,300.80, depending on qualifications and experience.
Remote work: Fully remote working arrangement within the United States.
Comprehensive healthcare coverage: Medical, dental, and vision insurance available from the first day of employment.
Financial protection: Life insurance and disability insurance coverage.
Paid time off: Paid leave benefits available from the first day of employment.
Retirement savings: Access to a 403(b) retirement plan.
Paid parental leave: Four weeks of parental leave at 100% pay.
Career development: Opportunities for professional growth, specialized training, and continued learning.
Well-being resources: Access to whole-person wellness programs and mental health resources.
Additional perks: Pet benefits and other employee support resources.
Professional growth: Opportunities to strengthen clinical documentation expertise and collaborate with experienced healthcare professionals.
Meaningful impact: Contribute to improved clinical documentation, healthcare quality, and accurate representation of patient care.