Clinical Document Improvement Specialist

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Clinical Document Improvement Specialist based in the United States.

This role is essential in ensuring that inpatient clinical documentation accurately reflects the severity of illness, risk of mortality, and full scope of patient care. The position operates at the intersection of clinical care, coding, and health information management, working closely with physicians, nurses, and coding teams to improve documentation quality and compliance.

Accountabilities

The specialist is responsible for reviewing inpatient medical records and ensuring that documentation accurately captures clinical complexity, supports coding accuracy, and aligns with regulatory standards.

• Conduct concurrent and retrospective reviews of inpatient records to assess completeness and accuracy of documentation.
• Query physicians and care teams to clarify diagnoses, procedures, and clinical details.
• Collaborate with physicians, HIM coders, nurses, and case management teams to ensure accurate assignment of diagnoses.
• Identify documentation gaps and initiate improvement opportunities to support correct DRG assignment and quality reporting.
• Monitor CDI program metrics and reporting tools to track trends and support continuous improvement.
• Educate clinical staff on documentation best practices, compliance standards, and the impact of accurate clinical documentation.

Requirements

This role requires strong clinical knowledge, CDI expertise, and the ability to collaborate effectively with multidisciplinary healthcare teams.

• Associate degree in Health Information Management, Nursing, or related clinical field required; RHIT/RHIA, CCDS, or CDIP certification required.
• Minimum of 3 years of experience in clinical documentation improvement, utilization review, case management, or critical care.
• Licensed Registered Nurse (single-state or multi-state) or equivalent clinical licensure preferred; foreign medical graduates with CDI certification may be considered.
• Strong understanding of inpatient hospital operations, DRG assignment, ICD-10 coding principles, and documentation standards.
• Excellent communication skills with the ability to engage physicians and clinical staff.
• Strong analytical and critical thinking skills with high attention to detail.
• Ability to work independently in a remote environment.

Benefits

• 100% remote work within the United States
• Comprehensive medical, dental, and vision insurance options
• Paid time off and holiday leave
• Retirement savings plan (401(k))
• Training and professional development opportunities
• Opportunity to work within a collaborative, multidisciplinary healthcare environment

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We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company.

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