Clinical Documentation Specialist

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.Key ResponsibilitiesReview clinical documentation for completeness, accuracy, and compliance with regulatory standardsEnsure documentation supports appropriate coding and billing requirementsCollaborate with physicians, nurses, and other clinical staff to clarify documentation gapsMaintain knowledge of clinical terminology, coding standards (ICD-10, CPT, HCPCS), and compliance requirementsMonitor and report on documentation quality metricsProvide feedback and education to clinical staff to improve documentation practicesAssist in audits and quality improvement initiatives related to clinical documentationMaintain confidentiality and adhere to HIPAA regulations and organizational policiesParticipate in cross-functional projects to optimize documentation workflowsRequired QualificationsBachelors degree in Nursing (RN), Health Information Management, or a related healthcare field2–5 years of experience in clinical documentation, coding, or health information managementKnowledge of medical terminology and healthcare documentation standardsFamiliarity with EHR systems and clinical workflow processesStrong attention to detail and organizational skillsExcellent written and verbal communication skillsAbility to work independently in a remote environmentUnderstanding of compliance, privacy, and regulatory requirementsPreferred QualificationsCertified Clinical Documentation Specialist (CCDS) credential or equivalentExperience with ICD-10, CPT, and HCPCS codingPrevious experience in hospital, clinical, or healthcare operations environmentsFamiliarity with quality improvement and documentation audit processesKnowledge of healthcare analytics and reporting toolsCompensationAnnual Salary Range: $70,000 – $95,000 USD, depending on experience, certifications, and healthcare expertiseBenefitsEligible employees may receive the following benefits:Comprehensive medical, dental, and vision insurance401(k) retirement plan with employer matchingPaid time off (PTO) including vacation, holidays, and sick leaveLife insurance and disability coverageFlexible remote work environmentProfessional development and certification supportEmployee wellness and assistance programsPotential performance-based bonusesWork Authorization RequirementApplicants must meet the following requirements:Must currently reside in the United StatesMust be legally authorized to work in the United StatesApplications from individuals residing outside the U.S. will not be considered

Salary : $70,000 - $95,000