Clinical Documentation Specialist

Job Summary

To support clinical documentation integrity, the full-time Clinical Documentation Specialist will perform audits, evaluate documentation compliance, and develop educational programs, all while working remotely during standard business hours.

Key responsibilities

• Conduct routine and ad hoc audits of CDI queries and documentation for compliance with standards and regulations
• Evaluate clinical evidence and ensure alignment with coding rules and guidelines
• Create and deliver comprehensive education programs and materials for providers on documentation best practices

Required qualifications

• Clinical Documentation Professional credential from the Association of Clinical Documentation Improvement Specialists obtained prior to hire
• High school diploma equivalency with 2 years of experience, or an Associate's/Bachelor's degree, or 4 years of relevant experience
• Expert understanding of CDI best practices and coding principles
• Proficiency with EHR systems and CDI software platforms
• Strong knowledge of DRG methodologies and CMS compliance