Clinical Documentation Improvement Specialist

Working remotely in a full-time capacity, the Clinical Documentation Improvement Specialist will conduct comprehensive clinical chart reviews to identify documentation opportunities, collaborate with healthcare teams, and ensure compliance with coding standards. Key responsibilities Perform daily, concurrent reviews of inpatient records to ensure accurate physician documentation at discharge Initiate compliant physician queries for ambiguous or missing documentation and follow up for timely responses Collaborate with coding and quality teams to maintain documentation that reflects the severity of illness and risk of mortality Required qualifications Bachelor's degree One of the following: RN, MD, or MD Equivalent (MBBS) 4+ years of direct patient care experience in inpatient settings, critical care, or strong med-surg experience 2+ years of prior Clinical Documentation Improvement experience Familiarity with encoder and DRG assignment, along with current knowledge of official coding guidelines