Clinical Documentation Specialist Remote

Remote Clinical Documentation Medical Professional (CDI/CDMP)
100% Remote | 3-Month Contract
Monday-Friday | 8-Hour Day Shift

Sigma Systems is seeking a Clinical Documentation Medical Professional (CDMP) to support a leading healthcare organization. This fully remote position focuses on improving the quality, accuracy, and completeness of inpatient clinical documentation while supporting appropriate DRG assignment, reimbursement accuracy, and quality outcomes.

The ideal candidate will have a strong clinical background and experience reviewing inpatient medical records, collaborating with physicians, and supporting Clinical Documentation Improvement (CDI) initiatives.

• Perform concurrent and retrospective reviews of inpatient medical records.

• Evaluate documentation for completeness, accuracy, specificity, and clinical validity.

• Identify opportunities for improved physician documentation to support accurate coding, severity of illness, risk adjustment, and reimbursement.

• Collaborate with physicians, coding professionals, and healthcare team members to resolve documentation gaps.

• Assist with accurate MS-DRG and APR-DRG assignment through documentation improvement efforts.

• Provide recommendations based on clinical knowledge, evidence-based practice, and documentation standards.

• Serve as a clinical documentation resource for physicians, coding staff, and other healthcare professionals.

• Support initiatives focused on documentation quality, compliance, reimbursement, and patient outcomes.

• Participate in education and process improvement activities related to clinical documentation integrity.

One of the following educational backgrounds is required:

• Graduate of an accredited RN Program

• Graduate of a Physician Assistant Program

• Foreign or Domestic Medical School Graduate (active physician license not required)

Proof of education is required at the time of submission.

• Minimum 3 years of clinical healthcare experience required.

• Experience with Clinical Documentation Improvement (CDI), Clinical Documentation Integrity, Utilization Review, Case Management, Coding, or Inpatient Clinical Review strongly preferred.

• Knowledge of MS-DRG, APR-DRG, and the Inpatient Prospective Payment System (IPPS) preferred.

• Experience reviewing inpatient medical records and collaborating with physicians preferred.

• Strong clinical assessment and analytical skills.

• Excellent written and verbal communication abilities.

• Ability to work independently in a remote environment.

• Strong attention to detail and documentation review skills.

• Proficiency with electronic medical record systems.

• Remote Position

• Monday-Friday Schedule

• 8-Hour Day Shift

• 3-Month Contract

This is an excellent opportunity for experienced clinical professionals seeking to leverage their clinical expertise in a remote Clinical Documentation Improvement environment.