RN Clinical Documentation Specialist

Job Summary

To support the accuracy of clinical documentation in a fully remote capacity, the Clinical Documentation Integrity Specialist will review medical records for completeness and compliance, collaborate with healthcare professionals, and identify opportunities for documentation improvement.

Key Responsibilities

• Review and evaluate medical record documentation for completeness, accuracy, and compliance
• Collaborate with physicians, nurses, and coding professionals to ensure appropriate clinical documentation
• Identify opportunities for documentation improvement to support coding accuracy, reimbursement, and clinical outcomes

Required Qualifications

• 2 years of clinical documentation improvement (CDI) experience
• Registered Nurse (RN) certification
• Knowledge of ICD-10-CM, MS-DRGs, coding guidelines, and compliance standards
• Proficiency with MS Office, email, VPNs, and video conferencing tools
• Experience using 3M and Epic preferred but not required