Senior Remote Clinical Documentation Specialist

Job Description & Requirements

Senior Remote Clinical Documentation Specialist

StartDate: 7/20/2026 Pay Rate: $48.00 - $60.00

POSITION: Senior Remote Clinical Documentation Specialist

DEPARTMENT: Health Information Management

START: ASAP

LOCATION: Remote

JOB DESCRIPTION: The Clinical Documentation Specialist Senior is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record by working directly with providers. This position is responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchal condition categories of the patient. This position will recognize opportunities for documentation improvement and hold collaborative discussions with providers. The Senior level is expected to function as a subject matter expert on the team and assist less experience team members in understanding and following operational policies. This role is responsible for training and onboarding new team members and participating in special projects assigned by the Mid Revenue Cycle leadership.

The Clinical Documentation Specialist Senior assesses clinical documentation through extensive medical record review and utilization of clinical judgment, deployment of artificial intelligence, and collaborating directly with the providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions. This position conducts independent research to ensure compliance when developing provider queries, while interpreting and applying evolving standards from governing bodies AHIMA and ACDIS and maintaining up-to-date knowledge of coding changes and updates released each April and October.

Extensive collaboration with physicians, mid-levels, nursing staff, other patient care givers to include developing and delivering education, which will be accomplished with zoom meetings, telephonic discussions, and email.

Additionally, the Clinical Documentation Specialist Senior will collaborate with the Health Information Management (HIM) coding staff and the Educators to ensure that appropriate reimbursement is received for the level of services rendered to patients, clinical information utilized in profiling and reporting outcomes is complete and accurate.

Essential Job Duties

• Perform extensive record review
• Reviews medical records for quality, completeness, and accuracy of documentation.
• Ensures that coded diagnoses accurately reflect level of patient care and patient status, including severity of illness and risk of mortality.
• Identifies gaps in documentation as well as conflicting or unspecified diagnoses and clarifies diagnoses with providers to assign the most accurate ICD 10CM/PCS code from the documentation.
• Must meet and maintain the quality and productivity measures established per polices.
• Work independently when reviewing each case, utilizing clinical judgement to determine when to contact the provider or inpatient coders.
• Provider Communcation and Education
• Delivers ongoing education to providers through collaboration and communication via zoom meetings, telephonic discussions, and email.
• Provides supplemental educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians.
• Needs to be proficient and knowledgeable on the different topics and
• diagnoses they query.
• The CDS Senior must tailor education to each provider service line based on the provider’s needs and documentation.
• Applies knowledge of standards and regulations while educating the physicians on different topics.
• Documentation Improvement
• Identify and share documentation improvement opportunities with providers to capture the patient's accurate severity of illness and risk of mortality, comorbid conditions, and all other condition categories.
• Compliance and Query Development
• Utilizes a combination of clinical knowledge and coding skills to develop clear, concise and compliant written and verbal queries to providers, seeking clarification on unclear, incomplete, or non-specified documentation.
• Utilizes software system and the Natural Language Processor (NLP) to review, compile clinical indicators for provider collaboration, code, collect, track, and report outcomes accurately and timely.
• Completes extensive independent research to be complaint while sending queries, interpret and abide by the governing bodies AHIMA and ACDIS and be up to date with the coding changes and updates occurring every April and October.
• Report clinical documentation improvement metrics
• Key Performance Indicators and additional significant metrics will be reported and discussed regularly, and as needed to the Medical Executive Committee via presentation to the Medical Records Committee and with other committees as directed.
• Team Support
• The Senior is expected to function as a subject matter expert for the team and assist less experience team members in following operational policies. This role is responsible for training and onboarding new team members.
• Special Projects
• The Senior will participate in special projects assigned by the Mid Revenue Cycle leadership.
  
  

Minimum Skills/Specialized Training Required

• Proven record of combining clinical knowledge and coding skills
• Ability to recognize opportunities for documentation improvement and hold collaborative discussions with
• providers to address the opportunities in documentation.
• Proficient in computer skills including MS Office, Optum 360 eCAC, Cerner EHR
• Organized, analytical, superior interpersonal and writing skills
• Dependable, self-directed with critical thinking, problem solving, and deductive reasoning
• Knowledge of healthcare regulatory environment
• Understand and support clinical documentation management strategies
• Must be flexible to accommodate clinician schedules
• Knowledge of Case Mix Index and how it is influenced.
  
  

Preferred Experience

• 4 years' experience in oncology
• Vizient experience
  
  

Qualifications

• Associate’s degree required; Bachelor’s preferred – Nursing, HIM, or another Healthcare related field
• EXPERIENCE/SKILLS/SPECIALIZED TRAINING - For Minimum Experience, describe the minimum length (use specific number of years, not a range) and type of work experience required to successfully perform the job. For Minimum Skills/Specialized Training, describe the particular skills, knowledge and abilities required, as well as the depth and/or breadth of those competencies.
• Minimum Experience Required
• A minimum six (6) years' acute care clinical documentation experience to include:
• Applying Medicare, Medicaid and Commercial payer regulations, charging and coding guidelines
• Healthcare regulations
• ICD-10-CM, ICD-10-PCS coding
• Performing independent queries.
• Any of the following Certifications is required: CCDS, CDIP, CDEI – Certified Documentation Expert Inpatient from AAPC required.
• In lieu of a certification listed above, an (active) RN will satisfy the certification requirement.
  
  

Benefits Guide Listed in "Attachments"

Facility Location

Boasting world-class beaches, a scenic harbor, barrier islands and year-round blue skies, Tampa offers all the attractions of a sunny, welcoming coastal destination. Visitors and residents alike relish the city’s luxurious beach resorts, laid-back lifestyle, sprawling parks and nature preserves, as well as the opportunity to soak up the sun any time of the year.

Job Benefits

Becoming an AMN Healthcare professional gives you the incredible opportunity to gain critical career experience, work with new people, and earn a highly competitive salary—but the perks don't stop there. There are many additional benefits to enjoy, including:

• Medical, dental and vision benefits
• Earned time off and paid holidays
• Paid continuing education time
• 401(K) retirement planning
• Short-term disability, life insurance, paid jury duty
• Access to the largest network of facilities and providers in the country
• Industry experienced workforce management team
• Licensure and certification reimbursement
  
  

About The Company

At AMN Healthcare, we strive to be recognized as the most trusted, innovative, and influential force in helping healthcare organizations provide quality patient care that continually evolves to make healthcare more human, more effective, and more achievable.