Remote Clinical Documentation Specialist I

Jobgether; United States; Remote; USD 67,000 - 124,000; Full time

Benefits offered by this job

Fully remote within United States

Comprehensive health coverage

403(b) retirement plan

Paid time off

Life and disability insurance

Parental leave

Professional development

Well-being resources

Pet benefits

Job summary

Jobgether is seeking a Clinical Documentation Specialist I based in the United States for a fully remote role. You will partner with physicians and nurses to improve accuracy and completeness of clinical records, focusing on SOI/ROM and quality indicators.

Responsibilities include educating care teams, conducting concurrent record reviews, and developing clarification requests. A strong clinical background and 5+ years in acute care are required, with CCDS/CDIP credentials as a plus.

Qualifications

• Minimum 5 years of acute care nursing or clinical experience.
• Active clinical credential (RN, PA, MD, CRNP, ACNPC, or ECFMG).
• Bachelor's or Master's in Nursing preferred.
• Relevant backgrounds in Health/Business/Public Health may be considered.
• Prior CDI experience is preferred.

Responsibilities

• Educate clinicians on documentation regulations and best practices.
• Communicate with physicians to ensure complete, accurate medical documentation.
• Conduct concurrent medical record reviews for completeness and compliance.
• Identify documentation gaps related to SOI, ROM, and quality indicators.
• Prepare and maintain CDI severity worksheets and clarification requests.
• Follow up on active cases to ensure timely responses.
• Collaborate with clinicians to resolve documentation discrepancies.
• Maintain accurate CDI data in documentation systems.

Skills

Acute care nursing

Documentation accuracy

Interdisciplinary collaboration

Clinical judgment

Analytical thinking

Education

Bachelor's or Master's in Nursing

CCDS or CDIP (advantage)

Tools

CDI software

Job description

Jobgether is seeking a Clinical Documentation Specialist I based in the United States for a fully remote role. You will partner with physicians and nurses to improve accuracy and completeness of clinical records, focusing on SOI/ROM and quality indicators.

Responsibilities include educating care teams, conducting concurrent record reviews, and developing clarification requests. A strong clinical background and 5+ years in acute care are required, with CCDS/CDIP credentials as a plus.