Inpatient Clinical Documentation Specialist

About reputed company

At reputed company, your work makes a meaningful impact.

We partner with hospitals and health systems nationwide to improve documentation accuracy, strengthen compliance, and ensure patient care is accurately represented. By combining deep clinical and coding expertise with advanced technology, our team delivers measurable results that support better patient outcomes and appropriate reimbursement.

We're committed to building a collaborative, high-performing culture where people are supported, challenged, and empowered to grow. With more than 200 professionals and a national network of clinical experts, you'll work alongside talented colleagues who value collaboration, innovation, clinical excellence, and a shared commitment to delivering exceptional results.

Proudly Great Place to Work Certified for three consecutive years, we're dedicated to creating an environment where our people can do their best work while making a real difference.

Job Summary

The Inpatient Clinical Documentation Specialist (CDS) partners with physicians, coding professionals, and clinical teams to improve the accuracy, completeness, and integrity of inpatient medical record documentation. Leveraging strong clinical judgment and CDI expertise, this role reviews concurrent and retrospective patient records, identifies documentation improvement opportunities, and issues compliant provider queries to ensure the patient's severity of illness, risk of mortality, and overall clinical picture are accurately reflected.

Working as an extension of our clients' Clinical Documentation Improvement (CDI) programs, the Inpatient CDS helps support accurate coding, appropriate reimbursement, regulatory compliance, and high-quality patient data while delivering exceptional client service.

What You'll Do

Review inpatient medical records to evaluate the accuracy, completeness, and clinical integrity of physician documentation

Identify documentation improvement opportunities and issue concise, compliant provider queries in accordance with reputed company and ACDIS best practices

Collaborate with physicians, coding professionals, and clinical staff to improve documentation quality and coding accuracy

Analyze clinical documentation, laboratory results, medications, physician orders, diagnostic testing, and other clinical information to validate reportable diagnoses and procedures

Perform concurrent, continued stay, and retrospective chart reviews while maintaining accurate workflow documentation and meeting client-specific productivity and quality expectations

Monitor query follow-up, reconciliation, and escalation activities in accordance with client workflows and turnaround expectations

Apply Official ICD-10-CM/PCS Coding Guidelines, Coding Clinic guidance, and client-specific clinical reputed company criteria throughout the documentation review process

Educate providers and clinical staff on documentation best practices that support accurate clinical representation and compliant reimbursement

Maintain a strong understanding of inpatient coding, DRG assignment, clinical documentation improvement, and healthcare regulations

Deliver high-quality work while collaborating effectively with internal CDI, coding, quality, and client teams in a fully remote environment

Qualifications

Required

Active Registered Nurse (RN) license

Minimum of 5 years of acute Inpatient Clinical documentation Improvement (CDI) experience within a large tertiary or trauma hospital environment

Experience working within electronic health record systems

Strong knowledge of inpatient CDI practices, physician documentation, ICD-10-CM/PCS coding guidelines, DRG assignment, and compliant query practices

Excellent clinical judgment, analytical thinking, problem-solving, and critical thinking skills

Strong written and verbal communication skills with the ability to effectively educate and collaborate with physicians and interdisciplinary healthcare teams

Ability to work independently while managing multiple priorities in a fully remote environment

Preferred

CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) certification

Experience supporting multiple client environments or consulting engagements

Familiarity with clinical validation principles and payer documentation requirements

Experience collaborating with inpatient coding, quality, and revenue cycle teams to improve documentation integrity and reimbursement outcomes

Work Environment & Expectations

Fully remote, full-time position (40 hours per week)

Monday through Friday during regular business hours

Company-issued equipment provided

Dedicated secure home workspace required

High-speed internet connection required

Strict adherence to HIPAA Privacy and Security requirements

Ability to work independently while maintaining productivity and quality expectations

Why reputed company

At reputed company, we believe exceptional people deserve exceptional support. That's