TEKsystems · 5 hours ago
Clinical Documentation Specialist
United States
Full-time
Remote
Mid Level
$35/hr - $41/hrTEKsystems is a leading provider of business and technology services, and they are seeking a Clinical Documentation Specialist. The role involves conducting reviews of medical records to ensure accurate representation of patient illness and treatment, collaborating with various hospital staff to improve documentation integrity and coding practices.
Information Technology
Responsibilities
Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes
Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment
Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication
Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries
Efficiently and effectively utilizes UnityPoint Health’s selected CDI software and processes (i.e. CDI worksheet and workflow, physician query, query and DRG reconciliation processes)
Meets the minimum productivity and quality assurance standards established by the CDI department
Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines
Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues
Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction
Collaborates with other hospital departments as needed and directed by CDI leaders
Qualification
Required
MUST be a RN with CDI experience!
Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient's illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes
Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record
Identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment
Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication
Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries
Efficiently and effectively utilizes UnityPoint Health's selected CDI software and processes (i.e. CDI worksheet and workflow, physician query, query and DRG reconciliation processes)
Meets the minimum productivity and quality assurance standards established by the CDI department
Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines
Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues
Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction
Collaborates with other hospital departments as needed and directed by CDI leaders
Benefits
Medical, dental & vision
Critical Illness, Accident, and Hospital
401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
Life Insurance (Voluntary Life & AD&D for the employee and dependents)
Short and long-term disability
Health Spending Account (HSA)
Transportation benefits
Employee Assistance Program
Time Off/Leave (PTO, Vacation or Sick Leave)
Company
TEKsystems
At TEKsystems, they understand people. Every year they deploy over 80,000 IT professionals at 6,000 client sites across North America,
Founded in 1994
10001+ employees
H1B Sponsorship
TEKsystems has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (46)
2024 (52)
2023 (33)
2022 (22)
2021 (36)
2020 (53)
Funding
Current Stage
Late StageLeadership Team
Ryan Skains
Vice President, TEKsystems Global Services
Recent News
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2026-02-03
2025-11-19
2025-10-29
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