About This Role
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. This role leverages strong clinical judgment and CDI expertise to review patient records, identify documentation improvement opportunities, and issue compliant provider queries. The specialist ensures the patient's severity of illness, risk of mortality, and overall clinical picture are accurately reflected, supporting accurate coding, appropriate reimbursement, regulatory compliance, and high-quality patient data.
Responsibilities
- 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 AHIMA 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 validity 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
Requirements
- 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
Nice to have:
- 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
Benefits
- Comprehensive medical, dental, and vision insurance
- 401(k) with company match
- Generous paid time off plus eight paid holidays
- Company-provided equipment
- Professional development, continuing education, leadership training, and internal career growth opportunities
- Complimentary annual CEUs
- Access to advanced coding education and learning resources
- Employee wellness resources and discount programs
- Referral bonus opportunities
- White glove onboarding designed to set you up for success
Important Details
- Schedule: Monday through Friday during regular business hours
- Dedicated secure home workspace required
- High-speed internet connection required
- Strict adherence to HIPAA Privacy and Security requirements
Application Process
- Multiple-choice assessment
- Phone call with a Talent Acquisition Specialist
- Video interview with the Hiring Manager (must be on camera)
About the Company
Enjoin partners with hospitals and health systems nationwide to improve documentation accuracy, strengthen compliance, and ensure patient care is accurately represented. The company combines deep clinical and coding expertise with advanced technology to deliver measurable results that support better patient outcomes and appropriate reimbursement. Enjoin has more than 200 professionals and a national network of clinical experts. It has been Great Place to Work® Certified for three consecutive years.
