Clinical Documentation Specialist - 100% Remote

Houston Methodist is seeking a detail-oriented Clinical Documentation Specialist to join our team in a fully remote capacity. In this role, you will ensure accurate and comprehensive medical documentation that supports quality patient care, compliance, and optimal reimbursement. You will collaborate with physicians, coders, and other healthcare professionals to enhance the clarity and integrity of medical records.

Responsibilities:

• Review patient medical records to ensure accurate clinical documentation.


• Collaborate with physicians and healthcare teams to clarify documentation discrepancies.


• Ensure compliance with coding guidelines, hospital policies, and regulatory standards.


• Conduct ongoing audits of documentation and provide feedback to improve accuracy.


• Educate medical staff on best practices for clinical documentation improvement (CDI).


• Analyze data to identify trends and opportunities for documentation enhancement.


• Assist in optimizing reimbursement and minimizing denials through accurate documentation.


• Maintain up-to-date knowledge of CDI practices and regulatory changes.


• Utilize CDI software and tools to track documentation improvements.


• Participate in multidisciplinary meetings to enhance documentation integrity.

Requirements:

• Bachelor's degree in Nursing (BSN), Health Information Management, or related field.


• Current RN, RHIA, RHIT, or CCS certification required.


• Minimum of 3 years of experience in clinical documentation improvement, coding, or healthcare compliance.


• Strong knowledge of ICD-10-CM/PCS coding and DRG assignment.


• Familiarity with CMS, Joint Commission, and other regulatory guidelines.


• Excellent communication, analytical, and problem-solving skills.


• Ability to work independently and manage multiple priorities in a remote setting.


• Proficiency in electronic health records (EHR) and CDI software.


• Detail-oriented with strong organizational skills.


• Commitment to maintaining patient confidentiality and data integrity.

Benefits:

• Competitive salary with performance-based incentives.


• Comprehensive health insurance (medical, dental, and vision).


• 401(k) retirement plan with employer contributions.


• Paid time off (PTO) and holidays.


• Continuing education and professional development opportunities.


• Employee wellness programs and mental health support.


• Flexible work schedule with 100% remote capability.


• Life and disability insurance coverage.


• Employee assistance program (EAP).


• Supportive and collaborative work culture.

Why Join Us?

Houston Methodist is a nationally recognized leader in healthcare, committed to excellence, innovation, and compassionate patient care. As part of our team, you’ll work in a dynamic environment where your expertise makes a real impact. We offer professional growth, outstanding benefits, and a culture that values integrity, respect, and teamwork.

How to Apply

If you are passionate about clinical documentation and want to be part of a leading healthcare organization, apply today! Submit your resume and cover letter through our official career portal or email us at Apply.

Join Houston Methodist and contribute to a healthier future—one patient record at a time!