Remote CDI Specialist — Clinical Documentation Expert

Jefferson Health; United States; Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical insurance

Tuition assistance

Retirement plans

Job summary

Jefferson Health is seeking a Clinical Documentation Specialist to review medical records and ensure accurate documentation that supports treatment decisions and outcomes. This role involves drafting physician queries and collaborating with coders and physicians to improve documentation, while working remotely in a compliant setting.

The specialist will educate clinicians on documentation guidelines, maintain HIPAA compliance, and utilize EHR and coding tools in a remote hospital environment.

Qualifications

• Bachelor of Science in Nursing required; RHIA/RHIT preferred.
• 5+ years in CDI or medical record documentation improvement.
• Familiarity with CMS/HIPAA standards and medical coding basics.

Responsibilities

• Review medical records to ensure complete and accurate documentation.
• Prepare compliant queries to physicians for clarification.
• Collaborate with coders and health team members to improve documentation.
• Educate physicians, nurse practitioners, and physician assistants on documentation guidelines.
• Work remotely in approved home environment.

Skills

CDI experience

Epic EHR

Medical records review

Interpersonal skills

Education

BSN

Health Information Management

Tools

3M DRG

MS Office

Job description

Jefferson Health is seeking a Clinical Documentation Specialist to review medical records and ensure accurate documentation that supports treatment decisions and outcomes. This role involves drafting physician queries and collaborating with coders and physicians to improve documentation, while working remotely in a compliant setting.

The specialist will educate clinicians on documentation guidelines, maintain HIPAA compliance, and utilize EHR and coding tools in a remote hospital environment.