Clinical Documentation Specialist (Medical)

TL;DR

Clinical Documentation Specialist (Medical): Directing efforts toward the integrity of clinical documentation through record review and consultation with an accent on accuracy of medical necessity and severity of illness. Focus on conducting concurrent reviews, formulating compliant queries, and educating healthcare providers.

Location: Remote (Must possess a valid license in the state of practice, USA)

Company

hirify.global is a large healthcare system dedicated to providing compassionate, person-centered care rooted in its mission and core values.

What you will do

• Review medical records to ensure the overall quality, completeness, and integrity of clinical documentation.
• Collaborate with physicians and healthcare teams to support accurate code assignment and medical necessity.
• Develop and deliver education to providers and staff regarding clinical documentation standards.
• Conduct concurrent reviews of patient health records to address legibility, clarity, and precision.
• Formulate compliant clarifications and queries following organizational integrity procedures.
• Utilize 3M/360 software to enter data and monitor CDI efficiencies and effectiveness.

Requirements

• Associate/Diploma Degree in Nursing, Health Information Technology (HIT), or an Advanced degree in nursing or medical field (NP/APN/PA).
• Current Registered Nurse License in the State of practice, RHIA, RHIT, or CCS certification.
• Licensure as a physician assistant (PA), Nurse Practitioner/Advanced Practice Nurse (NP/APN), or completion of medical school.
• Experience in Critical Care, Medical, or Surgical Inpatient Care Nursing or as an inpatient coder.
• Proficiency with Windows-based computer systems, including email and internet navigation.
• Accurate data entry skills with a minimum typing speed of 30 wpm.

Nice to have

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP).
• Two years of experience in inpatient care nursing or inpatient coding.
• Experience with databases, spreadsheet software, and presentation software.

Culture & Benefits

• Full-time employment within a mission-driven healthcare environment.
• Inclusive culture that honors the dignity of every person and embraces diverse perspectives.
• Commitment to professional ethics, honesty, and integrity in patient care.
• Equal Opportunity Employer focused on providing compassionate care.