Job Details

Clinical Documentation Specialist

Pride Health is hiring a Clinical Documentation Specialist to support our client's healthcare facility in Morganton, NC.

Job Details: Schedule: Full-time, 40 hours/week. Initial training: Monday–Friday, 8:00 AM–5:00 PM ET for approximately 1–2 weeks. After training: Flexible scheduling within 6:00 AM–6:00 PM ET.

Location: 100% Remote

Job Type: Local contract

Contract Length: 13-week Temp-to-Perm assignment

Pay Range: $40.00 to $43.00/hour*

*Pay offered is based on experience, expertise, credentialing, and education.

Duties:

• Conduct 15–16 inpatient chart reviews per day, including initial and follow-up reviews.
• Review records for clinical documentation accuracy, completeness, and clinical validation.
• Identify documentation opportunities affecting MCC/CC, MS-DRGs, CMI, severity of illness, and risk of mortality.
• Develop compliant, non-leading provider queries and follow up on responses.
• Collaborate with physicians, Coding, Quality, Revenue Cycle, and Compliance teams.
• Support denial prevention, audits, quality initiatives, and provider education.
• Maintain compliance with CDI, coding, regulatory, and privacy standards.

Requirements:

• Education: Healthcare-related education preferred.
• License(s): NA
• Certification(s): Active CCS, CDIP, or CCDS certification required
• Years of experience:
  • 3+ years of direct inpatient CDI/CDS experience in an acute-care hospital. Inpatient CDI experience is mandatory; coding-only or outpatient CDI does not work.
  • Strong knowledge of ICD-10-CM/PCS, inpatient coding guidelines, Coding Clinic, clinical criteria, and clinical validation.
  • Experience with MS-DRGs, MCC/CC capture, CMI, SOI/ROM, and compliant provider queries.
• Skills/Specialties/Technology:
  • Optum CAC experience preferred.
  • Strong communication, analytical, and independent-work skills.

For workers in the United States, PrideGlobal and its affiliates offers eligible employee's comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, pet insurance and employee discounts with preferred vendors.

Equal Employment Opportunity PrideGlobal and its affiliates are an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.

Fair Chance Employment PrideGlobal and its affiliates are a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including, the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us. Only applicable for San Francisco Candidates

Under the San Francisco Lactation in the Workplace Ordinance, we will provide written notice of lactation accommodation rights, and this notice will automatically be given upon hiring, any inquiry of parental leave or lactation accommodation. Only applicable for Kentucky positions: For this type of employment, state law requires a criminal record check as a condition of employment. This applies to direct care staff (Examples: RN, LPN, Nurse Aides, Therapists) referred to Kentucky nursing facilities, assisted living communities, or long-term care facilities, in accordance with KRS 216.793.