Clinical Documentation Specialist

Clinical Documentation Specialist (CDS)

Position Summary
The 100% Remote Clinical Documentation Specialist (CDS) is responsible for supporting accurate and complete clinical documentation within the acute-care hospital setting. The CDS will work collaboratively with physicians, nursing staff, coding professionals, and other clinical stakeholders to identify opportunities for improved clinical documentation, clarification, and accurate representation of the patient’s clinical condition and severity of illness.

The ideal candidate will have a Registered Nurse (RN) or Licensed Practical/Vocational Nurse (LPN/LVN) clinical background, demonstrated acute-care hospital Clinical Documentation Integrity (CDI) experience, and strong knowledge of clinical documentation and coding principles.

Key Responsibilities

• Perform concurrent and/or retrospective clinical documentation reviews for acute-care hospital patients.
• Review medical records to identify documentation that may require clarification or additional clinical specificity.
• Identify opportunities for compliant physician queries based on clinical indicators, patient presentation, diagnostic findings, treatment, and documented clinical conditions.
• Utilize Nuance CDE to perform CDI reviews, document findings, and manage physician queries.
• Collaborate with physicians, nursing staff, coders, and other members of the healthcare team to improve the completeness and accuracy of clinical documentation.
• Evaluate documentation for appropriate clinical support of diagnoses, procedures, complications, and severity of illness.
• Support accurate assignment of MS-DRGs, CC/MCCs, and other applicable reimbursement-related classifications through improved clinical documentation.
• Apply current CDI industry standards, official coding guidelines, and hospital policies when performing reviews and developing queries.
• Maintain appropriate documentation of CDI activity and follow established productivity and quality expectations.
• Communicate effectively with clinical and coding staff regarding documentation opportunities.
• Maintain confidentiality and comply with HIPAA, hospital policies, and applicable regulatory requirements.

Required Qualifications

• RN or LPN/LVN license in good standing.
• Prior Clinical Documentation Integrity (CDI) experience in an acute-care hospital setting.
• Hands-on experience with Nuance CDE — required.
• CCDS or CDIP certification — required.
• Strong understanding of acute-care clinical documentation and physician query processes.
• Knowledge of ICD-10-CM/PCS, MS-DRG methodology, CC/MCC capture, and clinical validation principles.
• Strong clinical assessment and critical-thinking skills.
• Excellent written and verbal communication skills.
• Ability to work independently while effectively collaborating with physicians, coders, and clinical teams.
• Strong computer skills and ability to navigate electronic medical records and CDI software.

Preferred Qualifications

• 5+ years of acute-care CDI experience.
• Experience with concurrent and retrospective CDI review.
• Experience working with complex medical/surgical patients.
• Familiarity with multiple EHR platforms and hospital CDI workflows.
• Experience with clinical validation and/or quality-focused CDI reviews.

Core Competencies

• Clinical knowledge and critical thinking CDI methodology and documentation review
• Physician query development
• Acute-care hospital experience
• Nuance CDE proficiency
• ICD-10-CM/PCS knowledge
• MS-DRG knowledge
• Communication and collaboration

Minimum Screening Requirements

1. RN or LPN/LVN clinical background
2. Acute-care hospital CDI experience
3. Nuance CDE experience
4. Active CCDS or CDIP certification