Remote Clinical Documentation Improvement Specialist

Jefferson Health; Philadelphia (Philadelphia County); Remote; USD 90,000 - 110,000; Full time

Job summary

Jefferson Health is seeking a Clinical Documentation Specialist to improve documentation accuracy and completeness in a largely remote role. You will identify documentation opportunities, generate professional queries, and collaborate with physicians, coders, and care teams to reflect the patient’s condition accurately within CMS and regulatory standards.

Required are a BSN or RHIA/RHIT with CCS/MD/DO considered; CCDS preferred; experience in CDI or coding is valued.

Qualifications

• Bachelor of Science in Nursing or RHIA/RHIT with CCS/MD/DO considered.

Responsibilities

• Review medical records for complete documentation of diagnoses, procedures and comorbidities.
• Prepare well-written queries for missing or clarifying information.
• Collaborate with coding staff to ensure accurate discharge diagnoses and reflection of patient status.
• Educate physicians and providers on coding and documentation requirements.
• Maintain remote-work productivity and document activity in CDI software.

Skills

Interpersonal skills

Analytical skills

Facilitation

Presentation skills

Education

Bachelor of Science in Nursing

Bachelor of Science in Health Information Management or related field

Tools

Epic EHR

3M DRG

MS Office

Job description

Jefferson Health is seeking a Clinical Documentation Specialist to improve documentation accuracy and completeness in a largely remote role. You will identify documentation opportunities, generate professional queries, and collaborate with physicians, coders, and care teams to reflect the patient’s condition accurately within CMS and regulatory standards.

Required are a BSN or RHIA/RHIT with CCS/MD/DO considered; CCDS preferred; experience in CDI or coding is valued.