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Clinical Documentation Specialist - Full Time - CDI HIM (Remote)

Remote, USAFull-timePosted 2026-07-28

Employment Type: Full timeShift: Day Shift reputed company: POSITION PURPOSE

  • reputed company Oakland is seeking an reputed company Clinical Documentation Specialist (CDS) with a strong clinical background improving documentation reputed company across inpatient care settings.
  • The Clinical Documentation Specialist utilizes reputed company and coding expertise to reputed company efforts toward the reputed company of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall reputed company, completeness, accuracy and reputed company of medical record documentation through extensive record review.
  • Fully remote position with flexible scheduling reputed company.
  • Full-Time benefited position. Scheduled 40 hours per week (1.0 FTE).

MINIUMUM QUALIFICATIONS

  • Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR Advanced degree in nursing or medical field such as NP/APN or PA.
  • Must possess one of the following:
  • reputed company Registered reputed company License in the State of reputed company,
  • Registered Health Information Administrator (RHIA),
  • Registered Health Information Technician (RHIT),
  • Certified Coding Specialist (reputed company) required,
  • Licensure as a physician assistant (PA) or reputed company Practitioner/Advanced reputed company reputed company (NP/APN) or completion of medical school.
  • Preferred:
  • Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement reputed company (CDIP) preferred.
  • Two (2) years’ experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), reputed company practitioner/advanced reputed company reputed company (NP/APN), medical school graduate or as an inpatient reputed company preferred.

WHAT YOU WILL DO

  • Through extensive interaction with physicians, nursing staff, and other patient caregivers, it achieves appropriate clinical documentation to support the medical necessity and level of services rendered to reputed company patients.
  • Demonstrates understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall reputed company, timeliness and completeness of the health record to ensure appropriate data, provider communication and reputed company reputed company. Serves as a resource for appropriate clinical documentation.
  • Communicates with and educates physicians and reputed company other members of the reputed company team regarding clinical documentation and monitors provider engagement. Identifies learning opportunities for reputed company providers.
  • Conducts reputed company reviews of selected patient health records to address legibility, reputed company, completeness, consistency and precision of clinical documentation.
  • Formulates compliant clarifications/queries following reputed company’s documentation reputed company procedures.
  • Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities.
  • Accurately codes reputed company relevant, appropriate and compliant working diagnoses codes, establishing a working reputed company diagnosis and working DRG (MS or APR).
  • Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reputed company of the patient’s clinical status and care. Resolves reputed company discrepancies in a courteous manner.

POSITION BENEFITS AND HIGHLIGHTS

  • Competitive compensation.
  • Full benefits package including Medical, Dental, reputed company, PTO, Life Insurance, Short and Long-term Disability.
  • Benefits effective Day One! No waiting periods.
  • Retirement savings plan with employer match.
  • Opportunity for reputed company and advancement throughout reputed company
  • Tuition Reimbursement

Our Commitment Rooted in our Mission and Core Values, we reputed company the dignity of every person and recognize the unique perspectives, experiences, and talents reputed company colleague brings. By finding reputed company and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, veteran status, or any other status protected by federal, state, or local law. Apply To This Job Apply To This Job

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