Clinical Documentation Improvement Specialist
Company Description RSD Human Resource Management Consultancy is a professional services firm focused on connecting organizations with specialized talent and providing end-to-end HR solutions. The consultancy supports clients in healthcare and related sectors, helping them improve operational efficiency, compliance, and workforce performance.
RSD emphasizes ethical practices, continuous improvement, and high-quality service delivery. Team members work in a collaborative, learning-oriented environment with access to diverse projects and clients. The organization values flexibility, accountability, and results-driven work.
Role Description This is a full-time remote role for a Clinical Documentation Improvement (CDI) Specialist at RSD Human Resource Management Consultancy. The CDI Specialist will review medical records on a daily basis to ensure that clinical documentation accurately reflects patient conditions, treatments, and the severity of illness.
The role includes collaborating with physicians, nurses, and coding teams to clarify diagnoses and procedures, and issuing queries when documentation is incomplete or ambiguous. The specialist will analyze trends in documentation quality, support clinical research and quality reporting initiatives, and contribute to the development of documentation standards and guidelines. Additional responsibilities include participating in training sessions, updating stakeholders on documentation best practices, and supporting audits to maintain regulatory and coding compliance.
Qualifications
- Strong Communication skills, including the ability to collaborate with multidisciplinary clinical and non-clinical teams and write clear, concise queries.
- Solid foundation in Medicine and clinical concepts, with experience interpreting medical records, diagnoses, and treatment plans.
- Experience in Training and education, with the ability to support documentation-related training for clinicians and staff.
- Proficiency in Research and Clinical Research methods to support data-driven documentation improvement and quality initiatives.
- Familiarity with ICD and CPT coding principles, clinical terminology, and healthcare compliance standards.
- Bachelor’s degree in Nursing, Medicine, Health Information Management, or a related clinical field; advanced certifications in CDI or coding (e.g., CCDS, CDIP, CCS) are preferred.
- Strong analytical skills, attention to detail, and ability to manage workload independently in a remote environment.
- Comfort with electronic health record (EHR) systems and standard office software tools.
