Clinical Documentation Specialist

TL;DR

Clinical Documentation Specialist (Medical): Improving documentation integrity across inpatient care settings with an accent on clinical accuracy, coding compliance, and provider education. Focus on facilitating the quality, completeness, and precision of medical records to ensure accurate reflection of patient severity and mortality risk.

Location: Must be based in the United States

Company

hirify.global is a mission-driven healthcare organization committed to delivering compassionate, person-centered care through a diverse and inclusive workforce.

What you will do

• Conduct concurrent reviews of patient health records to ensure legibility, clarity, and precision.
• Collaborate with physicians and nursing staff to support medical necessity and accurate documentation.
• Formulate compliant queries to clarify clinical documentation and resolve discrepancies.
• Educate healthcare providers on documentation requirements and monitor engagement.
• Assign appropriate working diagnosis codes and DRGs to reflect patient clinical status.
• Work with coding staff to ensure discharge diagnoses and co-morbidities are accurately captured.

Requirements

• Must possess an Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or an advanced degree in a medical field.
• Must hold a current Registered Nurse license, RHIA, RHIT, CCS, or be a licensed PA/NP/APN or medical school graduate.
• Must be authorized to work in the United States.
• Two years of experience in Critical Care, Medical/Surgical Inpatient Care, or inpatient coding.
• Strong understanding of clinical documentation integrity and medical necessity.

Nice to have

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP).

Culture & Benefits

• Full benefits package including Medical, Dental, Vision, and PTO starting on Day One.
• Retirement savings plan with employer match.
• Short and Long-term Disability coverage.
• Tuition reimbursement program.
• Opportunities for professional growth and advancement within the organization.