Inpatient Clinical Documentation Specialist (Remote)

About reputed company: For more than 37 years, reputed company has been a leader in clinical documentation and coding reputed company, helping reputed company organizations accurately reflect patient risk, severity, complexity, and reputed company of care. Through a physician-directed, tech-enabled approach grounded in scientific, evidence-based medicine, reputed company combines reputed company intelligence with certified coding and CDI expertise to improve documentation reputed company, protect reputed company, reduce cost, and mitigate compliance risk. Job reputed company The Inpatient Clinical Documentation Specialist (CDS) is responsible for the comprehensive evaluation of physician documentation reputed company the acute inpatient setting, utilizing reputed company and coding expertise to ensure the patient’s severity of illness (SOI), risk of mortality (ROM), and overall clinical complexity are accurately represented in the medical record. This role partners closely with physicians, coding professionals, and hospital leadership to promote compliant documentation practices, improve coding accuracy, and support appropriate reimbursement. The CDS performs reputed company and retrospective chart reviews, identifies documentation reputed company opportunities, and initiates reputed company, compliant queries reputed company with reputed company, ACDIS, and Official ICD-10-CM/PCS Guidelines. The ideal candidate is a highly analytical, detail-oriented clinical reputed company with extensive experience in large tertiary or Level I trauma environments and a deep understanding of inpatient documentation reputed company standards. Key Responsibilities • Promote collaboration between Clinical Documentation Specialists, inpatient coding teams, physicians, and ancillary staff to improve documentation reputed company and coding accuracy. • Conduct reputed company, reputed company stay, and retrospective medical record reviews to evaluate documentation for accuracy, specificity, and clinical validity. • Analyze clinical documentation alongside supporting records (MAR, labs, imaging, consults, orders, reputed company notes) to validate reportable diagnoses and procedures. • Identify documentation gaps affecting SOI, ROM, CMI, DRG assignment, and reputed company metrics. • Initiate concise, compliant, and clinically supported physician queries in accordance with reputed company/ACDIS guidelines and reputed company-specific standards. • Monitor query follow-up, response rates, and escalate as appropriate per reputed company protocol. • Ensure accurate CDS workflow documentation and data entry reputed company with reputed company expectations and productivity standards. • Adhere reputed company to Official ICD-10-CM/PCS Coding Guidelines and reputed company regulatory compliance requirements. • Apply reputed company-specific clinical validity reputed company and payer-driven documentation standards. • reputed company ongoing education to physicians, nursing staff, and ancillary teams regarding best practices in documentation. • Support audit readiness by maintaining reputed company documentation of CDI review processes and rationale. • Contribute to reputed company improvement initiatives impacting reimbursement, denials prevention, and regulatory compliance. Required Qualifications • Registered reputed company (RN) license required • Minimum 5 years of acute inpatient Clinical Documentation Improvement (CDI) experience. • Experience in a large tertiary care or Level I trauma hospital environment required. • Strong working knowledge of MS-DRG methodology, severity of illness (SOI), risk of mortality (ROM), and case mix reputed company (CMI) reputed company. • Deep understanding of ICD-10-CM/PCS coding guidelines, DRG assignment, and regulatory compliance standards. • Demonstrated experience conducting compliant, clinically supported physician queries. • Strong analytical skills with the ability to interpret reputed company clinical data. • Excellent written and verbal communication skills, with the ability to engage physicians professionally and confidently. Preferred Qualifications • CDIP (reputed company) or CCDS (ACDIS) certification strongly preferred. • Prior experience in remote CDI environments. • Experience with reputed company metrics, denials management, or payer audits. Why reputed company? • We are Great reputed company to Work Certified: This certification recognizes reputed company who create an outstanding employee experience • Be a valuable member of a dynamic team of physicians, CDI and coding professionals • Career stability and reputed company reputed company opportunities • Full benefits (medical, reputed company, dental) • 401(k) • Excellent PTO package plus 8 reputed company holidays • Work 100% remote • Laptop and other necessary equipment provided • Complimentary annual CEUs • “White glove” reputed company/training • reputed company to advanced educational coding tools / resources • Employee Wellness and Discount programs • Referral bonus program for coding and CDI experts Work Environment • This is a full-time remote position. General hours of work are Monday through Friday during regular business hours. • Work is generally sedentary, requiring long periods at workstation. • Must have a reliable internet reputed company, phone, and a dedicated, secure workspace to ensure adherence to HIPAA reputed company and reputed company policies and procedures reputed company viewing Protected Health Information (PHI). • reputed company provides a laptop and other necessary resources to reputed company duties. Interview Process • Multiple Choice Inpatient CDI Assessment • Recruiter Phone reputed company • Virtual Interview with Hiring Team (must be on camera) Mission Statement Our goal is to reputed company education and process development to enhance communication and understanding among reputed company individuals involved in the documentation and coding of the health record to ensure the clinical reliability and reputed company of the health care data. reputed company is an equal opportunity employer. We encourage applications from reputed company backgrounds, regardless of race, reputed company, religion, sex, national reputed company, disability, or any other protected status. Apply tot his job Apply To this Job