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.
Job Summary
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.
Key Responsibilities
• 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.
Required Qualifications
• 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.
Preferred Qualifications
• CDIP (AHIMA) or CCDS (ACDIS) certification strongly preferred.
• Prior experience in remote CDI environments.
• Experience with quality metrics, denials management, or payer audits.
Why Enjoin?
• We are Great Place to Work Certified: This certification recognizes employers who create an outstanding employee experience
• Be a valuable member of a dynamic team of physicians, CDI and coding professionals
• Career stability and professional growth opportunities
• Full benefits (medical, vision, dental)
• 401(k)
• Excellent PTO package plus 8 paid holidays
• Work 100% remote
• Laptop and other necessary equipment provided
• Complimentary annual CEUs
• “White glove” onboarding/training
• Access to advanced educational coding tools / resources
• Employee Wellness and Discount programs
• Referral bonus program for coding and CDI experts
Work Environment
• This is a full-time remote position. General hours of work are Monday through Friday during regular business hours.
• Work is generally sedentary, requiring long periods at workstation.
• Must have a reliable internet connection, phone, and a dedicated, secure workspace to ensure adherence to HIPAA Privacy and Security policies and procedures when viewing Protected Health Information (PHI).
• Enjoin provides a laptop and other necessary resources to perform duties.
Interview Process
• Multiple Choice Inpatient CDI Assessment
• Recruiter Phone Call
• Virtual Interview with Hiring Team (must be on camera)
Mission Statement
Our goal is to provide education and process development to enhance communication and understanding among all individuals involved in the documentation and coding of the health record to ensure the clinical reliability and integrity of the health care data.
Enjoin is an equal opportunity employer. We encourage applications from all backgrounds, regardless of race, color, religion, sex, national origin, disability, or any other protected status.
Apply Now
Apply Now
Job Summary
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.
Key Responsibilities
• 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.
Required Qualifications
• 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.
Preferred Qualifications
• CDIP (AHIMA) or CCDS (ACDIS) certification strongly preferred.
• Prior experience in remote CDI environments.
• Experience with quality metrics, denials management, or payer audits.
Why Enjoin?
• We are Great Place to Work Certified: This certification recognizes employers who create an outstanding employee experience
• Be a valuable member of a dynamic team of physicians, CDI and coding professionals
• Career stability and professional growth opportunities
• Full benefits (medical, vision, dental)
• 401(k)
• Excellent PTO package plus 8 paid holidays
• Work 100% remote
• Laptop and other necessary equipment provided
• Complimentary annual CEUs
• “White glove” onboarding/training
• Access to advanced educational coding tools / resources
• Employee Wellness and Discount programs
• Referral bonus program for coding and CDI experts
Work Environment
• This is a full-time remote position. General hours of work are Monday through Friday during regular business hours.
• Work is generally sedentary, requiring long periods at workstation.
• Must have a reliable internet connection, phone, and a dedicated, secure workspace to ensure adherence to HIPAA Privacy and Security policies and procedures when viewing Protected Health Information (PHI).
• Enjoin provides a laptop and other necessary resources to perform duties.
Interview Process
• Multiple Choice Inpatient CDI Assessment
• Recruiter Phone Call
• Virtual Interview with Hiring Team (must be on camera)
Mission Statement
Our goal is to provide education and process development to enhance communication and understanding among all individuals involved in the documentation and coding of the health record to ensure the clinical reliability and integrity of the health care data.
Enjoin is an equal opportunity employer. We encourage applications from all backgrounds, regardless of race, color, religion, sex, national origin, disability, or any other protected status.
Apply Now
Apply Now