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Role Description

The Clinical Documentation Specialist is responsible for ensuring the accuracy, completeness, and compliance of clinical documentation within electronic health records (EHR) and other medical systems. This role supports healthcare providers and clinical teams by reviewing documentation, facilitating proper coding, and ensuring adherence to regulatory and compliance standards.

The Clinical Documentation Specialist collaborates closely with physicians, nurses, coding staff, and compliance teams to maintain high-quality clinical records and improve patient care outcomes.

This is a fully remote position; however, applicants must currently reside in the United States and be legally authorized to work in the U.S. Applications from individuals residing outside the United States will not be considered.

• Review clinical documentation for completeness, accuracy, and compliance with regulatory standards
• Ensure documentation supports appropriate coding and billing requirements
• Collaborate with physicians, nurses, and other clinical staff to clarify documentation gaps
• Maintain knowledge of clinical terminology, coding standards (ICD-10, CPT, HCPCS), and compliance requirements
• Monitor and report on documentation quality metrics
• Provide feedback and education to clinical staff to improve documentation practices
• Assist in audits and quality improvement initiatives related to clinical documentation
• Maintain confidentiality and adhere to HIPAA regulations and organizational policies
• Participate in cross-functional projects to optimize documentation workflows

Qualifications

• Bachelors degree in Nursing (RN), Health Information Management, or a related healthcare field
• 2–5 years of experience in clinical documentation, coding, or health information management
• Knowledge of medical terminology and healthcare documentation standards
• Familiarity with EHR systems and clinical workflow processes
• Strong attention to detail and organizational skills
• Excellent written and verbal communication skills
• Ability to work independently in a remote environment
• Understanding of compliance, privacy, and regulatory requirements

Requirements

• Certified Clinical Documentation Specialist (CCDS) credential or equivalent
• Experience with ICD-10, CPT, and HCPCS coding
• Previous experience in hospital, clinical, or healthcare operations environments
• Familiarity with quality improvement and documentation audit processes
• Knowledge of healthcare analytics and reporting tools

Benefits

• Comprehensive medical, dental, and vision insurance
• 401(k) retirement plan with employer matching
• Paid time off (PTO) including vacation, holidays, and sick leave
• Life insurance and disability coverage
• Flexible remote work environment
• Professional development and certification support
• Employee wellness and assistance programs
• Potential performance-based bonuses

Work Authorization Requirement

• Must currently reside in the United States
• Must be legally authorized to work in the United States
• Applications from individuals residing outside the U.S. will not be considered