Clinical Documentation Specialist I

Key Responsibilities:

• Review inpatient and outpatient medical records to ensure accurate, complete, and compliant clinical documentation.
• Assign and validate principal diagnoses, secondary diagnoses, and procedures to support appropriate DRG, APC, and HCC assignment.
• Query physicians and clinical providers to clarify documentation and ensure specificity, accuracy, and present-on-admission status.

Requirements:

• Minimum of 5 years of experience as a clinical nurse, inpatient/outpatient coder, or 2 years as a Clinical Documentation Integrity Specialist.
• Strong understanding of clinical documentation practices in inpatient and outpatient settings.
• Proficiency with CDI software systems and reporting tools, and knowledge of medical coding systems including ICD-10-CM, CPT, HCPCS, and HCC methodologies.

Benefits:

• Remote work arrangement with structured weekday schedule (8:00 a.m. – 5:00 p.m.).
• Opportunity to work in a high-impact clinical role supporting quality care and accurate reimbursement.
• Comprehensive healthcare benefits and standard employee wellness programs (subject to eligibility).