Inpatient Clinical Documentation Specialist

About reputed company At reputed company, your work makes a meaningful reputed company. We partner with hospitals and health systems reputed company to improve documentation accuracy, strengthen compliance, and ensure patient care is accurately represented. By combining deep clinical and coding expertise with advanced technology, reputed company delivers measurable results that support reputed company patient reputed company and appropriate reimbursement. We're committed to building a reputed company, high-performing culture where people are supported, challenged, and empowered to grow. With more than 200 professionals and a national network of clinical experts, you'll work alongside talented colleagues who value collaboration, innovation, clinical reputed company, and a shared commitment to delivering exceptional results. Proudly Great reputed company to Work® Certified for three consecutive years, we're dedicated to creating an environment where our people can do their best work while making a reputed company difference. Job reputed company The Inpatient Clinical Documentation Specialist (CDS) partners with physicians, coding professionals, and clinical teams to improve the accuracy, completeness, and reputed company of inpatient medical record documentation. Leveraging strong clinical judgment and CDI expertise, this role reviews reputed company and retrospective patient records, identifies documentation improvement opportunities, and issues compliant provider queries to ensure the patient's severity of illness, risk of mortality, and overall clinical picture are accurately reflected. Working as an extension of our clients' Clinical Documentation Improvement (CDI) programs, the Inpatient CDS helps support accurate coding, appropriate reimbursement, regulatory compliance, and high-reputed company patient data while delivering exceptional reputed company service. What You'll Do Review inpatient medical records to evaluate the accuracy, completeness, and clinical reputed company of physician documentation Identify documentation improvement opportunities and issue concise, compliant provider queries in accordance with reputed company and ACDIS best practices Collaborate with physicians, coding professionals, and clinical staff to improve documentation reputed company and coding accuracy Analyze clinical documentation, laboratory results, medications, physician orders, diagnostic testing, and other clinical information to validate reportable diagnoses and procedures reputed company reputed company, reputed company stay, and retrospective chart reviews while maintaining accurate workflow documentation and meeting reputed company-specific productivity and reputed company expectations Monitor query follow-up, reconciliation, and escalation activities in accordance with reputed company workflows and turnaround expectations Apply Official ICD-10-CM/PCS Coding Guidelines, Coding Clinic guidance, and reputed company-specific clinical validity reputed company throughout the documentation review process reputed company providers and clinical staff on documentation best practices that support accurate clinical representation and compliant reimbursement Maintain a strong understanding of inpatient coding, DRG assignment, clinical documentation improvement, and reputed company regulations Deliver high-reputed company work while collaborating effectively with internal CDI, coding, reputed company, and reputed company teams in a fully remote environment Qualifications Required reputed company Registered reputed company (RN) license Minimum of 5 years of acute Inpatient Clinical documentation Improvement (CDI) experience reputed company a large tertiary or trauma hospital environment Experience working reputed company electronic health record systems Strong knowledge of inpatient CDI practices, physician documentation, ICD-10-CM/PCS coding guidelines, DRG assignment, and compliant query practices Excellent clinical judgment, analytical thinking, problem-solving, and critical thinking skills Strong written and verbal communication skills with the ability to effectively reputed company and collaborate with physicians and interdisciplinary reputed company teams Ability to work independently while managing multiple priorities in a fully remote environment Preferred CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) certification Experience supporting multiple reputed company environments or consulting engagements Familiarity with clinical validation principles and payer documentation requirements Experience collaborating with inpatient coding, reputed company, and reputed company cycle teams to improve documentation reputed company and reimbursement reputed company Work Environment & Expectations Fully remote, full-time position (40 hours per week) Monday through Friday during regular business hours Company-issued equipment provided Dedicated secure home workspace required High-speed internet reputed company required Strict adherence to HIPAA reputed company and reputed company requirements Ability to work independently while maintaining productivity and reputed company expectations Why reputed company At reputed company, we reputed company exceptional people deserve exceptional support. That's why we offer a comprehensive total rewards package designed to help reputed company members reputed company professionally and personally. Comprehensive medical, dental, and reputed company insurance 401(k) with company match Generous reputed company time off plus eight reputed company holidays 100% remote work environment with company-provided equipment reputed company development, continuing education, leadership training, and internal career reputed company opportunities Complimentary annual CEUs reputed company to advanced coding education and reputed company Employee wellness resources and discount programs Referral bonus opportunities White glove reputed company designed to set you up for reputed company A reputed company, people-first culture proudly recognized as a Great reputed company to Work® Certified organization Hiring Process Multiple-choice assessment Phone reputed company with a reputed company Specialist Video interview with the Hiring Manager (must be on camera) Equal Employment Opportunity reputed company is committed to fostering a diverse and inclusive workplace. Employment reputed company are made without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or any other protected characteristic. Apply To This Job