Job Overview
CODEMED, Inc. is seeking an experienced and detail-oriented Clinical Documentation Improvement (CDI) Specialist to join our team. The ideal candidate will collaborate with healthcare providers to improve the accuracy, completeness, and compliance of clinical documentation. This remote role requires a strong understanding of medical coding, clinical terminology, and regulatory requirements to enhance documentation that supports accurate coding, reimbursement, and quality outcomes.

Duties

Collaborate with physicians, coders, and healthcare staff to ensure clinical documentation accurately reflects the patient’s diagnoses and treatment.
Conduct thorough reviews of patient records for compliance with regulatory standards and guidelines.
Identify gaps, inconsistencies, or areas for improvement in clinical documentation to ensure it meets the highest standards of clarity and accuracy.
Provide education and feedback to providers and staff on proper documentation practices, coding guidelines, and clinical indicators.
Assist in the development and implementation of documentation improvement strategies and best practices.
Monitor metrics related to case mix index (CMI), query response rates, and documentation accuracy to identify trends and opportunities for improvement.
Utilize CDI software and tools to manage queries, track outcomes, and generate reports.
Stay updated on current industry standards, coding updates (ICD-10, CPT), and regulatory changes affecting clinical documentation.

Experience

Required active certification as a Clinical Documentation Specialist (e.g., CCDS or CDIP).
Minimum of 3-5 years of experience in clinical documentation improvement or related fields.
Strong clinical knowledge and familiarity with common medical conditions, treatments, and procedures.
Excellent communication and interpersonal skills for working with multidisciplinary teams.
Proficiency in CDI software and tools, with strong analytical and organizational abilities.

Key Competencies:

Attention to detail and ability to identify discrepancies in clinical documentation.
Strong problem-solving skills to address documentation challenges.
Ability to work independently in a remote environment while meeting deadlines and quality standards.
Proactive and self-motivated with a commitment to ongoing professional development.

Benefits:

Competitive salary
Flexible remote work environment
Comprehensive health, and vision insurance
Paid time off and holidays
Professional development and certification reimbursement

Job Types: Full-time, Contract

Pay: $46.31 - $49.95 per hour

Expected hours: 40 per week

Benefits:

Health insurance
Paid time off
Vision insurance

Schedule:

Monday to Friday

Work Location: Remote

CODEMED, Inc

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Clinical Documentation Specialist