Clinical Documentation Specialist
Job Description
Job Description
Job Title: Clinical Documentation Specialist
Location: Fountain Valley, California/Remote Role
Duration: 3+ Months
Job Type: Contract
Note: Applications 360, 3M and Iodine highly desired. Top 3 Keywords: 1- Clinical Documentation Integrity (CDI) 2- DRG Assignment & Concurrent Review 3- Epic & 3M 360 CDI Systems
Top Required Skills:
- Concurrent medical record review & clinical documentation improvement
- DRG assignment & coding collaboration
- Clinical communication & physician querying
Must-Have Skills:
- Concurrent review of inpatient medical records for accuracy and completeness
- Strong clinical knowledge to assess severity of illness, risk of mortality, and quality of care
- Experience identifying principal and secondary diagnoses and procedures
- Ability to assign and reconcile concurrent working DRGs
- Physician query development and compliance with CDI standards
- Strong understanding of coding and reimbursement guidelines (CMS, NCHS, AHA)
- Proficiency with clinical and collaboration systems (e.g., EPIC, 3M 360, Outlook, Teams, SharePoint)
- Excellent verbal and written communication skills
- Ability to work independently in a remote environment
- Strong attention to detail, organization, and multitasking abilities
- Strict adherence to HIPAA and patient confidentiality
Nice-to-Have Skills:
- CCDS and/or CDIP certification
- Experience with DRG mismatch analysis and retrospective reviews
- Experience supporting quality metrics, patient safety indicators, and compliance audits
- Experience using Iodine, Zoom, or similar clinical review tools
Key Responsibilities & Duties:
- Perform initial and subsequent concurrent CDI reviews for selected admissions and document findings
- Identify documentation clarification opportunities related to diagnosis specificity, quality, safety, and resource utilization
- Assign concurrent working DRGs and collaborate with physicians, coders, and CDI leadership to finalize DRGs
- Issue compliant physician queries to ensure accurate and complete clinical documentation
- Meet productivity, quality, compliance, and audit performance standards
- Maintain HIPAA compliance, follow organizational policies, and support special projects as assigned
Requirements:
- MD, BS, or higher in a healthcare-related field OR CCS-certified coder with strong clinical background
- Active clinical licensure (RN, PA, NP, MD, or FMD) and/or CCS certification (required)
- Strong understanding of CDI, coding guidelines, and reimbursement impact
- Ability to work autonomously and productively in a remote work environment
- English proficiency (read, write, speak)
Elevait Solutions is a disabled-veteran owned staffing and workforce solutions company built on purpose, integrity, and impact. We believe work should mean more than just a paycheck; it should fuel passion, growth, and fulfillment. That’s why we partner closely with both clients and job seekers to create connections that truly fit, not just fill a role.
Instead of forcing a match, we take the time to understand what drives each person and each organization, ensuring alignment that lasts. Our mission is to help people find careers that make them excited to show up every day—because when people love what they do, everyone wins.
From empowering veterans and transitioning service members to supporting underrepresented communities, Elevait Solutions is redefining what it means to build a career with purpose. We’re not just filling jobs, but we’re changing lives and strengthening teams that drive real results.