Clinical Documentation Specialist

Role Overview

We are seeking a Clinical Documentation Specialist to join our team for a 6-month contract-to-hire opportunity supporting a large provider client. This role is fully remote and requires expertise in clinical documentation improvement, coding, and provider communication to ensure accurate DRG assignments and high standards of medical record integrity.

Key Responsibilities

• Perform initial reviews of medical records within 24 to 48 hours of patient admission to assess documentation and accurately assign principal and secondary diagnoses along with related procedures, supporting correct DRG, risk of mortality, and severity categorization.
• Conduct follow-up record reviews every 2 to 3 days to maintain and support the appropriate working DRG assignment.
• Develop clear, compliant queries for providers addressing missing, unclear, or conflicting clinical documentation as necessary.
• Maintain daily communication with providers to ensure prompt responses to open documentation queries.
• Review and reconcile final coding DRG assignments following established reconciliation protocols.
• Stay current with Official Coding and Reporting Guidelines, AHA Coding Clinics, CMS directives, and other applicable agency guidance to align practice with the latest coding and clinical documentation trends.
• Exhibit strong verbal communication skills, including the ability to present information effectively to large groups.
• Encourage and foster a professional, team-focused, and service-oriented environment that aligns with company values and team objectives.
• Build and maintain collaborative relationships with HIM coding professionals to support documentation accuracy.
• Engage with leadership as necessary — per escalation procedures — to resolve provider queries and enhance clinical documentation improvement efforts.
• Troubleshoot any computer or technical issues efficiently to maintain productivity while working remotely.

Required Experience and Qualifications

• Proven ability to identify opportunities to improve clinical documentation quality and ensure medical record integrity.
• Experience drafting compliant clinical documentation queries.
• Strong knowledge of disease management, anatomy and physiology, medical terminology, pharmacology, and contemporary coding classification systems.
• Ability to understand and communicate effective documentation strategies clearly.
• Capable of working independently in a fully virtual environment or on-site when required by assignment travel.
• Familiarity with multiple encoder systems and electronic medical records including Optum eCAC, Solventum, EPIC, Cerner, and Meditech.
• Competence in applying coding conventions, official coding guidelines, and AHA Coding Clinic advice.
• Demonstrated analytical thinking and problem-solving skills.
• Certification as CCDS and/or CDIP required.
• Minimum of five years acute care hospital clinical CDI experience or inpatient coding auditor experience.

Preferred Qualifications

• Certification as CCDS or CDIP.
• Experience utilizing Computer Assisted Coding (CAC) systems.
• Bachelor’s degree in nursing or a background in Health Information Management (HIM).