Clinical Documentation Specialist I

Role overview

This opportunity is being shared for a partner employer, and that organization will handle applications and the next stages of the process. The hiring company is seeking a Clinical Documentation Specialist I located in the United States.

In this remote healthcare position, you will help ensure that patient records are complete, accurate, and compliant. You will work with physicians, nurses, and other clinical staff to resolve documentation questions, support correct coding, and uphold healthcare documentation standards. The role involves reviewing inpatient and outpatient records to confirm diagnoses, procedures, and indicators such as severity of illness and mortality risk. Your work will influence reimbursement accuracy, quality reporting, and the overall standard of clinical documentation. Strong clinical judgment, precision, and clear communication are essential, and you will also support training efforts that strengthen documentation practices across the organization.

Key accountabilities

• Examine inpatient and outpatient charts to confirm that documentation is accurate, complete, and aligned with compliance requirements.
• Validate principal and secondary diagnoses as well as procedures to support proper DRG, APC, and HCC assignment.
• Send documentation queries to physicians and other clinical professionals to improve specificity, accuracy, and present-on-admission capture.
• Work within ICD-10-CM, CPT, HCPCS, and payer rules to support coding and documentation compliance.
• Keep thorough logs of reviews, queries, and responses in CDI systems.
• Maintain daily productivity expectations for chart review and provider outreach.
• Use clinical judgment to evaluate severity of illness, risk of mortality, and patient complexity.
• Take part in education initiatives that improve documentation quality and coding precision.
• Support colleagues and leadership with workload balancing, process direction, and coverage-related decisions when required.
• Help refine CDI workflows and promote best practices through continuous improvement efforts.
• Continue professional growth through CEU requirements and certification progress, including pathways such as ACDIS certification.

Working schedule and additional information

This is a remote role with a structured weekday schedule from 8:00 a.m. to 5:00 p.m. The position is designed for work in a high-impact clinical setting where accuracy in documentation contributes directly to care quality and reimbursement outcomes.

Benefits and perks

• Remote setup with a fixed weekday schedule.
• Meaningful work that supports quality care and accurate reimbursement.
• Support for continuing education and certification development.
• Hands-on exposure to advanced CDI systems and processes.
• Potential career growth in clinical informatics, coding, and healthcare administration.
• Close collaboration with physicians and multidisciplinary clinical teams.
• Healthcare coverage and standard employee wellness programs, subject to eligibility.
• Direct contribution to better patient record quality and healthcare outcomes.

Data privacy and hiring process

Applications are reviewed through an AI-assisted matching process intended to compare candidates fairly and quickly against the role’s core requirements. The shortlist is then shared with the employer, and interviews, assessments, and final hiring decisions are handled by the company’s internal team.

By applying, candidates acknowledge that their personal data may be processed to evaluate eligibility and share relevant information with the employer, in line with applicable data protection laws. Candidates may exercise rights such as access, correction, deletion, and objection. AI tools may also be used to support parts of the hiring workflow, including resume review and response analysis, but final decisions are made by people.