Inpatient Clinical Documentation Specialist; Remote

About Enjoin

For more than 37 years, Enjoin has been a leader in clinical documentation and coding excellence, helping healthcare organizations accurately reflect patient risk, severity, complexity, and quality of care. Through a physician‑directed, tech‑enabled approach grounded in scientific, evidence‑based medicine, Enjoin combines advanced clinical intelligence with certified coding and CDI expertise to improve documentation quality, protect revenue, reduce cost, and mitigate compliance risk.

The Inpatient Clinical Documentation Specialist (CDS) is responsible for the comprehensive evaluation of physician documentation within the acute inpatient setting, utilizing advanced clinical and coding expertise to ensure the patient’s severity of illness (SOI), risk of mortality (ROM), and overall clinical complexity are accurately represented in the medical record.

This role partners closely with physicians, coding professionals, and hospital leadership to promote compliant documentation practices, improve coding accuracy, and support appropriate reimbursement. The CDS performs concurrent and retrospective chart reviews, identifies documentation integrity opportunities, and initiates clear, compliant queries aligned with AHIMA, ACDIS, and Official ICD‑10‑CM/PCS Guidelines.

The ideal candidate is a highly analytical, detail‑oriented clinical professional with extensive experience in large tertiary or Level I trauma environments and a deep understanding of inpatient documentation integrity standards.

• Promote collaboration between Clinical Documentation Specialists, inpatient coding teams, physicians, and ancillary staff to improve documentation integrity and coding accuracy.
• Conduct concurrent, continued stay, and retrospective medical record reviews to evaluate documentation for accuracy, specificity, and clinical validity.
• Analyze clinical documentation alongside supporting records (MAR, labs, imaging, consults, orders, progress notes) to validate reportable diagnoses and procedures.
• Identify documentation gaps affecting SOI, ROM, CMI, DRG assignment, and quality metrics.
• Initiate concise, compliant, and clinically supported physician queries in accordance with AHIMA/ACDIS guidelines and client‑specific standards.
• Monitor query follow‑up, response rates, and escalate as appropriate per client protocol.
• Ensure accurate CDS workflow documentation and data entry aligned with client expectations and productivity standards.
• Adhere strictly to Official ICD‑10‑CM/PCS Coding Guidelines and all regulatory compliance requirements.
• Apply client‑specific clinical validity criteria and payer‑driven documentation standards.
• Provide ongoing education to physicians, nursing staff, and ancillary teams regarding best practices in documentation.
• Support audit readiness by maintaining clear documentation of CDI review processes and rationale.
• Contribute to quality improvement initiatives impacting reimbursement, denials prevention, and regulatory compliance.

• Registered Nurse (RN) license required.
• Minimum 5 years of acute inpatient Clinical Documentation Improvement (CDI) experience.
• Experience in a large tertiary care or Level I trauma hospital environment required.
• Strong working knowledge of MS‑DRG methodology, severity of illness (SOI), risk of mortality (ROM), and case mix index (CMI) impact.
• Deep understanding of ICD‑10‑CM/PCS coding guidelines, DRG assignment, and regulatory compliance standards.
• Demonstrated experience conducting compliant, clinically supported physician queries.
• Strong analytical skills with the ability to interpret complex clinical data.
• Excellent written and verbal communication skills, with the ability to engage physicians professionally and confidently.

• CDIP (AHIMA) or CCDS (ACDIS) certification strongly preferred.
• Prior experience in remote CDI environments.
• Experience with quality metrics, denials management, or payer audits.

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• Be a valuable member of a dynamic team of physicians, CDI and coding…