Clinical Documentation Specialist - Remote

Overview

The Clinical Documentation Integrity Specialist (CDIS) is responsible for performing health record reviews to ensure accurate documentation of clinical conditions and procedures, collaborating with healthcare teams to maintain high-quality clinical documentation.

In Short

• Perform health record reviews to ensure accurate provider documentation.
• Collaborate with CDI specialists, coders, and healthcare providers.
• Ensure compliance with documentation standards and regulations.
• Utilize ICD-10-CM/PCS for accurate coding.
• Identify opportunities for documentation improvement.
• Communicate effectively with healthcare providers.
• Maintain productivity standards and quality compliance.
• Participate in professional development activities.
• Adhere to HIPAA and Code of Conduct policies.
• Work independently and manage time effectively.

Requirements

• Bachelor’s degree in Nursing or related medical field.
• Current RN, MD, or RHIA certification required.
• CCDS or CDIP certification preferred.
• At least two years of direct patient care or three years of inpatient coding experience.
• Strong critical-thinking and clinical knowledge.
• Proficiency in Microsoft Office and healthcare software.
• Excellent written and verbal communication skills.
• Experience with 3M 360 Encompass preferred.

Benefits

• Competitive salaries.
• Comprehensive benefits package including medical and dental.
• Tuition remission.
• Professional development opportunities.
• Supportive work environment.