Inpatient Clinical Documentation Specialist

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