Remote Clinical Documentation Specialist

RRHS; United States; Remote; USD 85,000 - 120,000; Full time

Job summary

RRHS is seeking a Clinical Documentation Specialist to support Unity Hospital remotely. The role focuses on accurate documentation for SOI, ROM, complexity of care, and quality, via extensive record review and teamwork with physicians and care staff.

Candidates should have an RN (or equivalent) with 5+ years acute care experience, and CCDS/CDIP certification within the eligibility window. Knowledge of CMS metrics and Epic is preferred.

Qualifications

• Registered nursing degree required; other clinical education may be considered.
• 5 years of adult acute care experience in med/surg, critical care, ER, or PACU (as of 03/02/2026).
• CCDS or CDIP certification exam within 6 months of eligibility if not certified.
• 2-3 years' experience with SNF payment methodologies and PDPM (SNF role).
• BSN or RN with BS in applicable field.

Responsibilities

• Reviews medical record for completeness and accuracy for SOI, ROM, complexity of care, and quality.
• Accurate and timely record review.
• Recognize opportunities for documentation improvement.
• Formulate clinically credible documentation clarifications.
• Request documentation clarifications for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety.
• Communicate effectively with physicians.
• Provide education to care team regarding the CDS process.
• Timely follow up on all cases and resolution of clarifications.
• Participate in Team Meetings.
• Manage multiple priorities.
• Communicate with HIM staff to resolve discrepancies.
• Input data accurately into department software.

Education

RN degree

BSN or RN with BS

Epic EMR knowledge

Tools

Epic EMR

Nuance CDE One

Job description

RRHS is seeking a Clinical Documentation Specialist to support Unity Hospital remotely. The role focuses on accurate documentation for SOI, ROM, complexity of care, and quality, via extensive record review and teamwork with physicians and care staff.

Candidates should have an RN (or equivalent) with 5+ years acute care experience, and CCDS/CDIP certification within the eligibility window. Knowledge of CMS metrics and Epic is preferred.