Clinical Documentation Specialist RN; Remote

Clinical Documentation Specialist RN (Remote)

Location:

Remote. Candidates must live in TX, LA, WA, FL, or GA.

As a Clinical Documentation Specialist RN, you will improve the quality and completeness of clinical documentation to ensure accurate reimbursement, measure outcomes, and educate patient‑care teams. Your analysis will support institutions in achieving high‑quality, compliant charting while enhancing patient safety and financial performance.

Exempt

• Analyze medical records for DRGs, complications, and comorbidities; identify trends and recommend documentation improvements.
• Facilitate documentation modifications through collaboration with physicians, nursing staff, and coding personnel.
• Ensure appropriate reimbursement by verifying the completeness of clinical information and supporting accurate DRG assignment.
• Support outcome measurement and reporting by maintaining accurate clinical data.
• Educate staff on documentation best practices and coding requirements.
• Track and follow up on documentation requests, completing DRG/worksheet updates as needed.
• Provide expertise on DRG payer issues, optimization strategies, and referral policies.

• Medical School graduate with a focus on Western medicine.
• Minimum one year of clinical experience preferred.
• Certifications (required or preferred):
  • CCDS – Clinical Documentation Specialists (ACDIS)
  • CDIP – Certified Documentation Integrity Practitioner (AHIMA)
  • CCS – Certified Coding Specialist (AHIMA)
• Proficiency in speaking, reading, and writing English.
• Strong analytical, problem‑solving, and communication skills.
• Ability to work well with physicians, coders, and other clinical staff.

• Open record review to improve documentation quality.
• Follow up with clinical personnel for missing information and track responses.
• Maintain accurate DRG worksheets and assist in final diagnosis confirmation.
• Educate internal customers on documentation opportunities and reimbursement optimization.

• Work attire: business professional.
• On‑call requirement: may be required during emergencies.
• Travel: none required; travel outside Houston Metropolitan area not required.