Remote CDI Specialist: Clinical Documentation & Compliance

Jefferson Health; Alabama; Remote; USD 60,000 - 80,000; Full time

Benefits offered by this job

Medical Insurance

Tuition Assistance

Retirement Plans

Wellness Programs

Job summary

Jefferson Health seeks aClinical Documentation Specialist to review medical records and improve documentation accuracy for CMS and regulatory reporting. The role supports remote work and collaborates with physicians, coders, and care teams to ensure the most accurate documentation of diagnoses and procedures.

The position emphasizes independent work in a compliant setting, ongoing education, and proactive communication with clinicians to optimize coding and patient care documentation.

Qualifications

• Bachelor of Science in Nursing required.
• Bachelor of Science in Health Information Management or related field.
• CCDS/CDIP certification preferred; RN/BSN preferred.
• Experience with Medicare reimbursement and coding structures preferred.
• 5 years Critical Care/Emergency or 5 years Medical-Surgical experience preferred.
• 2-3 years CDI or 5 years Coding experience preferred.

Responsibilities

• Review medical records concurrently for completeness and regulatory compliance.
• Prepare well written queries to obtain missing or clarifying information from physicians.
• Collaborate with coding staff to ensure discharge diagnoses and comorbidities are accurately reflected.
• Educate physicians and clinicians on documentation improvement and coding accuracy.
• Maintain CDI software tracking and stay current with coding guidelines and best practices.

Skills

Communication skills

Analytical skills

Independent work

Interpersonal skills

Education

Bachelor of Science in Nursing

Bachelor of Science in Health Information Management

Other healthcare field cert/degree

Tools

Epic EHR

3M DRG

MS Office

Job description

Jefferson Health seeks aClinical Documentation Specialist to review medical records and improve documentation accuracy for CMS and regulatory reporting. The role supports remote work and collaborates with physicians, coders, and care teams to ensure the most accurate documentation of diagnoses and procedures.

The position emphasizes independent work in a compliant setting, ongoing education, and proactive communication with clinicians to optimize coding and patient care documentation.