Clinical Document Improvement Specialist

Overview

This remote role, based in the United States, is offered through a partner employer that handles the application review and hiring process. The position focuses on ensuring that inpatient documentation fully and accurately reflects patient acuity, mortality risk, and the overall scope of care. It sits at the intersection of clinical practice, coding, and health information management, requiring a strong mix of clinical insight, precision, and cross-functional communication.

The specialist reviews medical records, spots missing or unclear details, and works with physicians, nurses, coders, and other care team members to support compliant documentation, accurate DRG assignment, and reliable reimbursement outcomes. The role also supports CDI education, training, reporting, and ongoing program improvement. It is best suited to a healthcare professional who is comfortable in a highly analytical, communication-intensive, and process-oriented environment.

Key responsibilities

• Review inpatient charts both during the stay and after discharge to verify that the record accurately reflects illness severity, mortality risk, and documentation completeness.
• Reach out to physicians and care teams with verbal or written clarification requests when diagnoses, procedures, or clinical details need further explanation.
• Work closely with physicians, HIM coders, nurses, and case management staff to help ensure principal and secondary diagnoses are assigned correctly.
• Detect documentation deficiencies and raise opportunities that improve DRG accuracy and support quality reporting.
• Track CDI metrics and reporting outputs to identify trends, highlight problem areas, and strengthen continuous improvement efforts.
• Support education for clinical staff on documentation standards, compliance expectations, and the impact of precise documentation on care and reimbursement.

Requirements

• An associate degree in Health Information Management, Nursing, or another related clinical discipline is required.
• Depending on background, RHIT, RHIA, CCDS, or CDIP certification is required.
• At least 3 years of experience in clinical documentation improvement, utilization review, case management, or critical care is required.
• A Registered Nurse license, either single-state or multi-state, is preferred; comparable clinical licensure may also be acceptable.
• Foreign medical graduates with CDI certification may be considered.
• Working knowledge of inpatient hospital workflow, DRG logic, ICD-10 coding concepts, and documentation compliance standards is essential.
• Strong verbal and written communication skills are needed to engage physicians and other clinical professionals in documentation clarification.
• Excellent analytical ability, sound critical thinking, and careful attention to detail are important.
• The ability to work independently in a remote setting while handling multiple reviews and deadlines is required.

Benefits

• Fully remote work arrangement anywhere within the United States.
• Medical, dental, and vision coverage options.
• Paid time off plus holiday leave.
• 401(k) retirement savings plan.
• Training and professional growth opportunities in CDI and health information management.
• Collaboration within a multidisciplinary healthcare environment.

Additional information

This opportunity is managed through a partner company, which oversees application screening and the next steps in the hiring process. A shortlist of strong matches is shared with the employer, while interviews and assessments are conducted by the employer’s internal team.

Privacy and data use

By applying, candidates agree that personal data may be processed to assess eligibility and shared with the hiring employer under applicable legal bases, including legitimate interest and pre-contractual measures. Applicants may exercise privacy rights such as access, correction, deletion, and objection at any time.

Artificial intelligence tools may be used to assist with application review, resume analysis, response assessment, and spotting possible inconsistencies or verification signals. These tools support the recruitment team but do not replace human judgment, and final hiring decisions are made by people.