Inpatient Clinical Documentation Specialist

Enjoin; United States; Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Medical, dental, and vision insurance

401(k) with company match

100% remote work with company-provided

CEUs and professional development

Job summary

Enjoin is seeking an Inpatient Clinical Documentation Specialist (CDS) to partner with physicians, coding teams, and clinical staff to improve inpatient documentation accuracy and completeness. You will review records, issue compliant queries, and support accurate severity, mortality, and reimbursement while ensuring regulatory compliance.

Leverage strong clinical judgment and CDI expertise to drive documentation improvements, collaborating across CDI, coding, quality, and client teams in a

Qualifications

• Active RN license required.
• 5+ years of acute inpatient CDI experience in large hospital.
• Experience with electronic health records systems.
• Strong knowledge of inpatient CDI practices, ICD-10-CM/PCS, DRG assignment, and compliant query practices.
• Excellent communication skills for education and collaboration with physicians and teams.
• Ability to work independently while managing multiple priorities remotely.

Responsibilities

• Review inpatient records to evaluate accuracy, completeness, and clinical integrity of physician documentation.
• Identify documentation improvement opportunities and issue concise, compliant provider queries per AHIMA/ACDIS.
• Collaborate with physicians, coding professionals, and clinical staff to improve documentation quality and coding accuracy.
• Analyze clinical data, labs, meds, orders, and tests to validate reportable diagnoses and procedures.
• Perform concurrent, continued stay, and retrospective chart reviews while meeting productivity and quality expectations.
• Monitor query follow-up, reconciliation, and escalation per client workflows.
• Apply ICD-10-CM/PCS coding guidelines and client validity criteria throughout reviews.
• Educate providers on documentation best practices to support accurate representation and reimbursement.
• Maintain understanding of inpatient coding, DRG assignment, and healthcare regulations.
• Deliver high-quality work in a fully remote environment with cross-team collaboration.

Skills

Clinical judgment

Analytical thinking

Problem-solving

Critical thinking

Written and verbal communication

Independent work

Education

RN license

Job description

About Enjoin

At Enjoin, your work makes a meaningful impact.

We partner with hospitals and health systems nationwide to improve documentation accuracy, strengthen compliance, and ensure patient care is accurately represented. By combining deep clinical and coding expertise with advanced technology, our team delivers measurable results that support better patient outcomes and appropriate reimbursement.

We're committed to building a collaborative, high-performing culture where people are supported, challenged, and empowered to grow. With more than 200 professionals and a national network of clinical experts, you'll work alongside talented colleagues who value collaboration, innovation, clinical excellence, and a shared commitment to delivering exceptional results.

Proudly Great Place to Work® Certified for three consecutive years, we're dedicated to creating an environment where our people can do their best work while making a real difference.

Job Summary

The Inpatient Clinical Documentation Specialist (CDS) partners with physicians, coding professionals, and clinical teams to improve the accuracy, completeness, and integrity of inpatient medical record documentation. Leveraging strong clinical judgment and CDI expertise, this role reviews concurrent and retrospective patient records, identifies documentation improvement opportunities, and issues compliant provider queries to ensure the patient's severity of illness, risk of mortality, and overall clinical picture are accurately reflected.

Working as an extension of our clients' Clinical Documentation Improvement (CDI) programs, the Inpatient CDS helps support accurate coding, appropriate reimbursement, regulatory compliance, and high-quality patient data while delivering exceptional client service.

What You'll Do

• Review inpatient medical records to evaluate the accuracy, completeness, and clinical integrity of physician documentation
• Identify documentation improvement opportunities and issue concise, compliant provider queries in accordance with AHIMA and ACDIS best practices
• Collaborate with physicians, coding professionals, and clinical staff to improve documentation quality and coding accuracy
• Analyze clinical documentation, laboratory results, medications, physician orders, diagnostic testing, and other clinical information to validate reportable diagnoses and procedures
• Perform concurrent, continued stay, and retrospective chart reviews while maintaining accurate workflow documentation and meeting client-specific productivity and quality expectations
• Monitor query follow-up, reconciliation, and escalation activities in accordance with client workflows and turnaround expectations
• Apply Official ICD-10-CM/PCS Coding Guidelines, Coding Clinic guidance, and client-specific clinical validity criteria throughout the documentation review process
• Educate providers and clinical staff on documentation best practices that support accurate clinical representation and compliant reimbursement
• Maintain a strong understanding of inpatient coding, DRG assignment, clinical documentation improvement, and healthcare regulations
• Deliver high-quality work while collaborating effectively with internal CDI, coding, quality, and client teams in a fully remote environment

Qualifications

Required

• Active Registered Nurse (RN) license
• Minimum of 5 years of acute Inpatient Clinical documentation Improvement (CDI) experience within a large tertiary or trauma hospital environment
• Experience working within electronic health record systems
• Strong knowledge of inpatient CDI practices, physician documentation, ICD-10-CM/PCS coding guidelines, DRG assignment, and compliant query practices
• Excellent clinical judgment, analytical thinking, problem-solving, and critical thinking skills
• Strong written and verbal communication skills with the ability to effectively educate and collaborate with physicians and interdisciplinary healthcare teams
• Ability to work independently while managing multiple priorities in a fully remote environment

Preferred

• CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) certification
• Experience supporting multiple client environments or consulting engagements
• Familiarity with clinical validation principles and payer documentation requirements
• Experience collaborating with inpatient coding, quality, and revenue cycle teams to improve documentation integrity and reimbursement outcomes

Work Environment & Expectations

• Fully remote, full-time position (40 hours per week)
• Monday through Friday during regular business hours
• Company-issued equipment provided
• Dedicated secure home workspace required
• High-speed internet connection required
• Strict adherence to HIPAA Privacy and Security requirements
• Ability to work independently while maintaining productivity and quality expectations

Why Enjoin

At Enjoin, we believe exceptional people deserve exceptional support. That's why we offer a comprehensive total rewards package designed to help our team members thrive professionally and personally.

• Comprehensive medical, dental, and vision insurance
• 401(k) with company match
• Generous paid time off plus eight paid holidays
• 100% remote work environment with company-provided equipment
• Professional development, continuing education, leadership training, and internal career growth opportunities
• Complimentary annual CEUs
• Access to advanced coding education and learning resources
• Employee wellness resources and discount programs
• Referral bonus opportunities
• White glove onboarding designed to set you up for success
• A collaborative, people-first culture proudly recognized as a Great Place to Work® Certified organization

Hiring Process

• Multiple-choice assessment
• Phone call with a Talent Acquisition Specialist
• Video interview with the Hiring Manager (must be on camera)

Equal Employment Opportunity

Enjoin is committed to fostering a diverse and inclusive workplace. Employment decisions are made without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic.