Clinical Documentation Specialist

Voted one of Chicago's Best Places to Work by the Chicago Tribune for the ninth year in a row, Clarity Partners is hiring!

Clarity Partners is seeking a fully remote Clinical Documentation Specialist. This role is responsible for improving the overall quality, accuracy, and completeness of clinical documentation within the legal medical record. The Clinical Documentation Specialist will collaborate closely with physicians, Health Information Management (HIM), and coding staff to support appropriate reimbursement and reflect the true severity of illness and risk of mortality for patients.

Responsibilities

• Review inpatient medical records on a concurrent basis to assess the accuracy, completeness, and clarity of clinical documentation.
• Facilitate appropriate documentation in the medical record through extensive interaction with physicians, HIM, and coding staff to ensure optimal reimbursement and the highest level of SOI/ROM for services rendered.
• Initiate and manage provider queries to obtain missing, unclear, or conflicting documentation needed to support accurate diagnoses and treatments.
• Educate physicians and clinical staff on clinical documentation standards, coding guidelines, and reimbursement opportunities on an ongoing basis.
• Apply strong knowledge of medical terminology, clinical concepts, and procedures to identify documentation and reimbursement opportunities.
• Monitor acute care (inpatient) medical records for diagnoses, treatments, and follow-up entries to validate accurate documentation and coding.
• Collaborate with coding and quality teams to support accurate case mix index (CMI), quality metrics, and compliance with regulatory requirements.
• Participate in ongoing process improvement initiatives related to clinical documentation integrity.

Requirements:

• Bachelor’s degree in Nursing, Health Information Management, or a related healthcare field required.
• License to practice as a Registered Nurse (any state); or credentialed as RHIA, RHIT, or CCS.
• CCDS (Certified Clinical Documentation Specialist – ACDIS) or CDIP (Certified Documentation Improvement Practitioner – AHIMA) credential required.
• Minimum of 1 year of acute care (inpatient) concurrent Clinical Documentation Specialist experience.
• 3+ years of overall clinical, coding, or health information management experience in an acute care hospital setting preferred.
• Strong understanding of ICD-10-CM/PCS coding, DRG assignment, and reimbursement methodologies.
• Excellent communication and interpersonal skills with the ability to effectively educate and influence physicians and clinical staff.
• High attention to detail, strong analytical skills, and ability to work independently in a fast-paced environment.

Clarity is committed to fair and equitable compensation practices. For the Clinical Documentation Specialist role, the base hourly pay range is $40.00/hr. – $60.00/hr. The range represents a good faith estimate that Clarity reasonably expects to pay for this job at the time of posting. Compensation will depend upon an individual’s skills, experience, qualifications, location, and other relevant factors. The salary pay range is subject to change and may be modified at any time.