Clinical Documentation Improvement Specialist (FT- 1.0 FTE, Remote)

Lensa; United States; Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a Clinical Documentation Improvement Specialist to enhance the quality and accuracy of medical records. This remote role offers the opportunity to work collaboratively with healthcare professionals, ensuring compliance with coding regulations and improving documentation through education and support. Ideal candidates will possess a strong background in nursing or an equivalent medical field, along with relevant certifications. If you are passionate about improving patient care through meticulous documentation, this is the perfect opportunity for you.

Qualifications

• Bachelor's degree in Nursing or equivalent medical program required.
• At least one professional certification in clinical documentation.

Responsibilities

• Conduct concurrent reviews of inpatient medical records for quality improvement.
• Collaborate with healthcare professionals and provide education on coding.

Skills

Clinical Documentation Improvement

ICD-10-CM & PCS Coding

Communication Skills

Organizational Skills

Education

Bachelor's degree in Nursing (RN)

Accredited Medical Program (MD, DO, NP)

Professional Certification (CCS, CCDS, CDIP)

Tools

Epic

3M 360 Encoder

Job description

Clinical Documentation Improvement Specialist (FT- 1.0 FTE, Remote)

Lensa is the leading career site for job seekers at every stage of their career. Our client, Bozeman Health, is seeking professionals. Apply via Lensa today!

Approved Remote States: Arizona, Florida, Georgia, Idaho, Iowa, South Dakota, Texas, South Carolina, Wisconsin, North Carolina, Montana

Position Summary

The Clinical Documentation Improvement Specialist (CDIS) conducts concurrent reviews of inpatient medical records to improve documentation quality, accuracy, and completeness. Using clinical expertise and current coding systems (ICD-10-CM & PCS), the CDIS ensures proper code assignment aligned with the patient's clinical condition and care. The role involves collaborating with providers through education and physician queries to support severity of illness, quality metrics, and regulatory compliance. The CDIS also maintains expertise in coding principles, regulations, and serves as a resource for clinicians, coders, and Revenue Cycle teams.

Required Minimum Qualifications

• Bachelor's degree in Nursing (RN) or completion of an accredited or equivalent international medical program.
• Current licensure as a Registered Nurse (RN) or a graduate of an accredited advanced medical program (MD, DO, NP, MBBS, or equivalent).
• At least one professional certification: CCS, CCDS, CDIP, RHIA, or RHIT.

Preferred Qualifications

• Three years of experience in medical/surgical or critical care nursing, CDI or inpatient coding in an acute care setting, or experience with Epic and 3M 360 Encoder systems.

Essential Job Functions

Ensure ethical, accurate, and complete coding; conduct concurrent reviews; collaborate with healthcare professionals; utilize clinical documentation systems; identify data integrity issues; maintain HIPAA compliance; participate in meetings and training; provide education; recommend process improvements; generate reports; stay updated with CMS regulations; meet productivity and quality standards.

Knowledge, Skills, and Abilities

• Sound judgment, professionalism, tact, discretion, confidentiality, and ability to work in a busy environment.
• Strong communication skills; organizational and prioritization abilities.

Schedule and Physical Requirements

Requires regular attendance, possible beyond standard hours, on-call work, and physical ability to perform tasks including lifting, sitting, standing, walking, climbing, bending, reaching, pushing/pulling, and visual/cognitive tasks.