Clinical Documentation Specialist

Role overview

This remote opportunity is for a Clinical Documentation Specialist working anywhere in the United States. The role supports accurate, compliant, and high-quality clinical records by reviewing inpatient documentation in detail and partnering with care teams to improve the completeness of patient charts.

The position is posted on behalf of a partner employer, which handles the application review and all subsequent hiring steps. The work is centered on strengthening documentation accuracy, supporting coding integrity, and helping ensure records reflect the true severity of illness, risk of mortality, and overall clinical complexity.

What you will do

• Review inpatient medical records each day to identify documentation opportunities that need clarification or strengthening.
• Assess whether the chart accurately captures the patient’s condition, illness severity, and risk of mortality.
• Work with physicians, coders, coding educators, auditors, case managers, and quality staff to improve documentation practices.
• Complete first-pass admission reviews, establish working DRGs, and keep CDI software records current.
• Revise working DRGs when new clinical evidence or physician responses support a different assignment.
• Send compliant physician queries when documentation is missing, ambiguous, inconsistent, or requires further detail.
• Apply established CDI standards and regulatory requirements to remain aligned with compliance expectations.
• Share workload concerns and review-volume needs to help balance assignments across the CDI team.
• Use EHR platforms, CDI tools, and coding systems to support efficient documentation review workflows.

Requirements

• A bachelor’s degree is mandatory.
• Active licensure or professional qualification as an RN, MD, or equivalent medical degree such as MBBS.
• At least 4 years of direct inpatient patient-care experience in settings such as acute care, critical care, emergency, or med-surg.
• At least 2 years of prior Clinical Documentation Improvement experience.
• Working knowledge of encoder tools, DRG assignment methods, and clinical coding workflows.
• Strong understanding of official coding guidelines, Coding Clinics, medical terminology, anatomy, physiology, microbiology, and disease processes.
• Hands-on experience with EHR systems, CDI software, and coding technology.
• Strong analytical thinking, troubleshooting ability, and sound clinical judgment.
• Clear communication and interpersonal skills, especially for discussing complex documentation issues with physicians.
• CCDS or CDIP certification is preferred.
• Additional background in coding, case management, utilization review, or inpatient acute care is advantageous.

Benefits and compensation

• Annual salary range of $61,000 to $101,000, depending on skills, experience, training, certifications, and organizational needs.
• Fully remote work available across the United States.
• Medical, prescription, dental, and vision insurance coverage.
• Paid holidays plus personal and family sick time.
• Potential eligibility for discretionary bonus programs.
• Parental leave and adoption support.
• 401(k) retirement plan.
• Basic and supplemental life insurance coverage.
• Health Savings Account and Flexible Spending Account options.
• Short-term and long-term disability benefits.
• Student loan repayment assistance.
• Tuition reimbursement and ongoing professional development opportunities.
• Skills training, certification support, employee referral programs, and community engagement initiatives.
• Additional support programs such as emergency childcare assistance and mobility benefits.

Application and data handling

Applications are reviewed through an AI-assisted matching process designed to shortlist candidates against the role’s core requirements. The shortlist is then shared with the hiring employer, while interviews, assessments, and final decisions are managed by that employer’s internal team.

By applying, candidates acknowledge that personal data will be processed to evaluate eligibility and share relevant information with the employer. This is based on legitimate interest and pre-contractual measures under applicable data protection laws, including GDPR. Applicants may request access, correction, deletion, or objection regarding their data. AI tools may also assist with resume review and response analysis, though final hiring decisions are made by people.