Remote Clinical Documentation Specialist

Remote – must sit AK, CA, MT, OR, TX, or WA The Clinical Documentation Specialist (CDS) is responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation. A key success factor of this process is educating providers through the query process and independently supporting them with education and feedback to accurately reflect the patient's true clinical picture within the medical record. In partnering with the coding team, the CDS will be an expert with ICD-10, NS-DRG and APR-DRG assignment. The CDS's primary responsibility will be to obtain appropriate clinical documentation through extensive review of provider, nursing, ancillary, and other patient caregivers' documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients. The CDS exercises their judgment and discretion to ensure the clinical information utilized in analyzing and reporting outcomes is complete and accurate. On an ongoing basis, the CDS is responsible for supporting the direction and focus of education for providers and the coding staff within their assigned scope of work. The CDS must exercise independent judgment, critical thinking, ability to work independently while interpreting and following CMS guidelines, organizational policies, and procedures.

The Clinical Documentation Specialist conducts thorough reviews of medical records to ensure accurate, complete, and compliant documentation that reflects the patient’s clinical status. They collaborate closely with providers, offering education and feedback through the query process, and partner with coding teams to support accurate ICD-10 and DRG assignment. The CDS also leads documentation improvement initiatives, builds dashboards, and reports, and independently manages provider education and performance insights to enhance clinical and financial outcomes.