Clinical Documentation Specialist

GeBBS Healthcare Solutions, Inc.; United States; Remote; USD 55,000 - 83,000; Full time

Job summary

GeBBS Healthcare Solutions, Inc. is seeking a Clinical Documentation Specialist for a 6-month remote project. The role supports accuracy of clinical documentation in acute-care hospital settings, collaborating with physicians, nurses, coders, and CDI professionals.

The ideal candidate will have an RN or LPN background, CDI experience, and CCDS/CDIP certification, with strong knowledge of ICD-10-CM/PCS, MS-DRG, and physician query processes.

Qualifications

• Prior CDI experience in an acute-care hospital setting.
• Hands-on experience with Nuance CDE.
• CCDS or CDIP certification required.
• Knowledge of ICD-10-CM/PCS, MS-DRG methodology, CC/MCC capture.
• Strong communication and critical-thinking skills.

Responsibilities

• Perform concurrent and retrospective CDI reviews for acute-care hospital patients.
• Review medical records to identify documentation clarification needs.
• Identify opportunities for compliant physician queries based on clinical indicators and diagnoses.
• Utilize Nuance CDE to perform CDI reviews and manage physician queries.
• Collaborate with physicians, nursing staff, coders, and clinical teams to improve documentation.
• Evaluate documentation for appropriate clinical support of diagnoses and procedures.
• Support accurate assignment of MS-DRGs, CC/MCCs, and other classifications.
• Apply current CDI industry standards and hospital policies.

Skills

CDI experience

Nuance CDE

Critical thinking

Communication skills

Independent work

Education

RN/LPN background

CCDS or CDIP certification

Tools

EMR systems

CDI software

Job description

GeBBS Healthcare Solutions is a leading provider of Revenue Cycle Management (RCM) and Risk Adjustment services, helping healthcare organizations optimize operations, improve financial performance, maintain compliance, and enhance the patient experience. Recognized as a KLAS® Top Performer, GeBBS combines innovative technology, industry expertise, and a commitment to excellence to deliver measurable results for clients across the healthcare industry. We are dedicated to being a trusted healthcare partner by upholding the highest standards of quality, information security, and compliance.

At GeBBS, we foster a collaborative and growth-oriented culture where employees are empowered to develop their skills, advance their careers, and make a meaningful impact in transforming healthcare.

Clinical Documentation Specialist (CDS) - 6-Month Project

The 100% Remote Clinical Documentation Specialist (CDS) is a 6-month project position responsible for supporting accurate and complete clinical documentation within the acute-care hospital setting. The CDS will work collaboratively with physicians, nursing staff, coding professionals, and other clinical stakeholders to identify opportunities for improved clinical documentation, clarification, and accurate representation of the patient’s clinical condition and severity of illness.

Project Duration: Approximately 6 months , with potential for extension based on client and business needs.

The ideal candidate will have a Registered Nurse (RN) or Licensed Practical/Vocational Nurse (LPN/LVN) clinical background , demonstrated acute-care hospital Clinical Documentation Integrity (CDI) experience , and strong knowledge of clinical documentation and coding principles.

Key Responsibilities

• Perform concurrent and/or retrospective clinical documentation reviews for acute-care hospital patients.
• Review medical records to identify documentation that may require clarification or additional clinical specificity.
• Identify opportunities for compliant physician queries based on clinical indicators, patient presentation, diagnostic findings, treatment, and documented clinical conditions.
• Utilize Nuance CDE to perform CDI reviews, document findings, and manage physician queries.
• Collaborate with physicians, nursing staff, coders, and other members of the healthcare team to improve the completeness and accuracy of clinical documentation.
• Evaluate documentation for appropriate clinical support of diagnoses, procedures, complications, and severity of illness.
• Support accurate assignment of MS-DRGs, CC/MCCs, and other applicable reimbursement-related classifications through improved clinical documentation.
• Apply current CDI industry standards, official coding guidelines, and hospital policies when performing reviews and developing queries.
• Maintain appropriate documentation of CDI activity and follow established productivity and quality expectations.
• Communicate effectively with clinical and coding staff regarding documentation opportunities.
• Maintain confidentiality and comply with HIPAA, hospital policies, and applicable regulatory requirements.

Required Qualifications

• Prior Clinical Documentation Integrity (CDI) experience in an acute-care hospital setting.
• Hands-on experience with Nuance CDE — required.
• CCDS or CDIP certification — required.
• Strong understanding of acute-care clinical documentation and physician query processes.
• Knowledge of ICD-10-CM/PCS, MS-DRG methodology, CC/MCC capture, and clinical validation principles.
• Strong clinical assessment and critical‑thinking skills.
• Excellent written and verbal communication skills.Ability to work independently while effectively collaborating with physicians, coders, and clinical teams.
• Strong computer skills and ability to navigate electronic medical records and CDI software.

Preferred Qualifications

• 5+ years of acute-care CDI experience.
• Experience with concurrent and retrospective CDI review.
• Experience working with complex medical/surgical patients.
• Familiarity with multiple EHR platforms and hospital CDI workflows.
• Experience with clinical validation and/or quality-focused CDI reviews.

Core Competencies

• Clinical knowledge and critical thinking CDI methodology and documentation review