Clinical Documentation Specialist

Dahl Consulting; Long Beach (CA); Hybrid; USD 62,000 - 69,000; Full time

Benefits offered by this job

Benefits package

Remote work

Job summary

Dahl Consulting is seeking a Clinical Documentation Specialist for a remote project supporting clinical documentation integrity and denials management initiatives. You will review inpatient records and collaborate with providers to improve documentation accuracy and reduce denials while ensuring quality patient care outcomes.

The ideal candidate has CDI expertise, strong physician collaboration skills, and comfort working across multiple health information systems. Remote role with W2 engagement.

Qualifications

• Minimum 3 years inpatient CDI experience.
• Experience reviewing clinical documentation and managing physician query workflows.
• Strong knowledge of ICD-10-CM/PCS, MS-DRG and APR-DRG methodologies, SOI and ROM indicators.
• Ability to meet productivity and quality metrics.

Responsibilities

• Conduct concurrent and retrospective reviews of medical records to identify documentation gaps and opportunities for improvement.
• Develop and issue compliant physician queries to clarify clinical documentation.
• Monitor outstanding queries and follow up with providers within established timeframes to ensure timely resolution.
• Support denials prevention and clinical validation efforts through accurate documentation review.
• Collaborate with coding, CDI, utilization review, and clinical teams to improve documentation quality.
• Assign and monitor working DRGs, SOI, and ROM indicators.
• Analyze documentation trends and provide recommendations to improve documentation integrity.
• Maintain productivity standards, including daily and weekly chart review goals.
• Ensure compliance with applicable documentation, coding, and regulatory guidelines.
• Serve as a documentation subject matter expert and resource for clinical stakeholders.

Skills

Inpatient CDI experience

Physician query workflows

Excellent communication

Education

RHIA (Registered Health Information Administrator)

RHIT (Registered Health Information Technician)

CCDS/CDIP certification

Tools

EMR/EHR systems

Physician query management tools

Job description

Title

Clinical Documentation Specialist

Location and Hours

Remote (Hours: 8:00am-5:00pm PST required)

Job Type

Contract (6 months)

Compensation

$45.00 - $50.00 per hour (W2)

Industry

Hospital & Healthcare

Start Date

Monday, 11/16

Required Credentials

• RHIA (Registered Health Information Administrator)
• RHIT (Registered Health Information Technician)
• CCS (Certified Coding Specialist) credential or RN (Registered Nurse) or MD graduate/educated in foreign country
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)

About the Role

Our firm is partnering with a well-established healthcare consulting organization to identify a Clinical Documentation Specialist for a remote project supporting clinical documentation integrity and denials management initiatives. This opportunity focuses on reviewing inpatient medical record documentation, collaborating with providers to improve documentation accuracy, and helping healthcare organizations reduce denials while ensuring quality patient care outcomes. The ideal candidate is an experienced CDI professional who thrives in a production-driven environment, excels at physician collaboration, and is comfortable working across multiple documentation and health information systems.

Job Description

As a Clinical Documentation Specialist, you will provide clinical documentation review and physician query support for a healthcare client engagement. You will help ensure medical records accurately reflect the patient's clinical condition while supporting quality metrics, reimbursement accuracy, regulatory compliance, and denials prevention efforts.

Responsibilities

• Conduct concurrent and retrospective reviews of medical records to identify documentation gaps, inconsistencies, and opportunities for improvement.
• Develop and issue compliant physician queries to clarify clinical documentation.
• Monitor outstanding queries and follow up with providers within established timeframes to ensure timely resolution.
• Support denials prevention and clinical validation efforts through accurate documentation review.
• Collaborate with coding, CDI, utilization review, and clinical teams to improve documentation quality.
• Assign and monitor working DRGs, severity of illness (SOI), and risk of mortality (ROM) indicators.
• Analyze documentation trends and provide recommendations to improve documentation integrity.
• Maintain productivity standards, including daily and weekly chart review goals.
• Ensure compliance with applicable documentation, coding, and regulatory guidelines.
• Serve as a documentation subject matter expert and resource for clinical stakeholders.

Qualifications

• RHIA (Registered Health Information Administrator) or RHIT (Registered Health Information Technician) credential.
• CCDS (Certified Clinical Documentation Specialist) or CDIP/CCIP (Certified Documentation Improvement Practitioner) certification.
• Minimum 3 years of inpatient Clinical Documentation Integrity (CDI) experience.
• Experience reviewing clinical documentation and managing physician query workflows.
• Strong understanding of: ICD-10-CM/PCS coding guidelines MS-DRG and APR-DRG methodologies Severity of Illness (SOI) and Risk of Mortality (ROM) indicators Clinical validation and denials prevention concepts
• Experience working within multiple EMR/EHR and documentation systems.
• Excellent written and verbal communication skills.
• Ability to meet established productivity and quality metrics.

Preferred

Experience supporting healthcare organizations in California. Experience with denials management and clinical validation reviews. CCS (Certified Coding Specialist), RN, or equivalent clinical background. Experience analyzing documentation trends and presenting findings to stakeholders. Knowledge of HCC (Hierarchical Condition Category) methodologies. Previous consulting or remote CDI experience.

Benefits

Dahl Consulting is proud to offer a comprehensive benefits package to eligible employees that will allow you to choose the best coverage to meet your family’s needs. For details, please review the DAHL Benefits Summary: https://www.dahlconsulting.com/benefits-w2fta/.

Equal Opportunity Statement

As an equal opportunity employer, Dahl Consulting welcomes candidates of all backgrounds and experiences to apply.