Remote Inpatient Coder Jobs in Smyrna, TN (NOW HIRING)

Acute Care Hospital Experience Required

• High School Diploma required with submission

Online certification verification required with submission.

Required:

• Active, unrestricted Registered Nurse (RN) license

Preferred Certifications:

• Certified Clinical Documentation Specialist (CCDS) - ACDIS
• Certified Documentation Improvement Practitioner (CDIP) - AHIMA
• Certified Coding Specialist (CCS) - AHIMA
• Registered Health Information Administrator (RHIA) - AHIMA
• Registered Health Information Technician (RHIT) - AHIMA

• Monday - Friday
• Occasional weekend coverage may be required based on client needs

The CDI Specialist is responsible for improving the overall quality and completeness of clinical documentation within the medical record. Through concurrent review of patient records, the CDI Specialist collaborates with physicians, nursing staff, coding professionals, case management, and other healthcare team members to ensure documentation accurately reflects severity of illness, risk of mortality, quality measures, and resource utilization.

The CDI Specialist identifies opportunities for documentation clarification through compliant physician queries and helps ensure documentation supports accurate coding, reimbursement, quality reporting, and denial prevention.

This role requires strong clinical knowledge, critical thinking skills, and a thorough understanding of ICD-10-CM/PCS coding guidelines, MS-DRG assignment, APR-DRG methodologies, and regulatory requirements.

The CDI Specialist will work collaboratively with HIM, Coding, Case Management, Utilization Review, Physician Advisors, and providers to support accurate and complete clinical documentation.

• Conduct concurrent reviews of inpatient medical records to identify documentation improvement opportunities.
• Initiate compliant physician queries to clarify diagnoses, procedures, severity of illness, risk of mortality, and present-on-admission indicators.
• Collaborate with Coding, HIM, Case Management, Utilization Review, and clinical teams to promote complete and accurate documentation.
• Ensure documentation supports appropriate MS-DRG and APR-DRG assignment.
• Assist with reducing denials through accurate clinical documentation and physician education.
• Monitor documentation trends and identify opportunities for process improvement.
• Participate in physician education initiatives related to documentation best practices.
• Maintain productivity and quality standards established by the client.
• Stay current on regulatory requirements, coding guidelines, and CDI best practices.
• Assist leadership with special projects and additional duties as assigned.

• Active RN license
• Acute Care Hospital CDI experience required
• Experience performing concurrent inpatient chart reviews
• Experience writing compliant physician queries
• Strong understanding of clinical documentation improvement principles
• Knowledge of MS-DRGs, APR-DRGs, Severity of Illness (SOI), and Risk of Mortality (ROM)
• Experience collaborating with physicians and interdisciplinary teams

• CCDS and/or CDIP certification
• Strong understanding of ICD-10-CM/PCS coding guidelines
• Experience with mortality reviews, quality initiatives, and denial prevention
• Experience with Epic, Cerner, Meditech, or other major EMR systems