Remote Clinical Documentation Specialist (OR)

Position Overview

Join a mission-driven team as a Remote Clinical Documentation Specialist with an operating room (OR) focus and help redefine how healthcare data impacts patient outcomes. This fully remote opportunity is designed for professionals who excel in clinical documentation, medical terminology, and digital health record systems. With a clear focus on ensuring documentation aligns with compliance and clinical standards, you’ll help empower medical teams and ensure accurate data reflects the true complexity of care provided. If you’re ready to contribute to a fast-paced, values-centered organization that prioritizes excellence and professional development, this is your opportunity to thrive.

Key Responsibilities

Documentation Quality Review

Ensure Completeness and Accuracy

• Review surgical and OR-related patient records to ensure all documentation is complete, timely, and clinically appropriate.
• Identify discrepancies or documentation gaps and collaborate with physicians and OR teams for clarification.
• Ensure diagnoses and procedures are supported by evidence-based notes.

Clinical Collaboration

Foster Real-Time Improvements

• Work closely with surgeons, anesthesiologists, and nursing staff to facilitate real-time documentation improvements.
• Participate in physician education sessions to enhance awareness of documentation standards and compliance.
• Provide input on documentation trends that may impact clinical coding or reimbursement.

Regulatory Compliance

Maintain Standards and Readiness

• Monitor clinical documentation for accuracy about CMS and payer-specific guidelines.
• Ensure adherence to HIPAA, HITECH, and hospital-specific documentation standards.
• Proactively manage audit readiness by supporting strong documentation integrity.

Work Environment

Remote-First Culture

Flexibility and Independence

• Enjoy the flexibility of a work-from-home setup that respects your time, autonomy, and productivity.
• Collaborate virtually with interdisciplinary teams through secure communication platforms.
• Access digital tools and training resources from anywhere, ensuring continued growth.

Supportive Team Structure

Peer Learning and Recognition

• Join a community of remote health information professionals who value peer learning, mentorship, and shared success.
• Engage in monthly virtual workshops, peer coaching sessions, and team-building activities.
• Experience a professional environment where performance is recognized and initiative is rewarded.

Tools and Technologies Used

Documentation Systems

Electronic Health Records (EHRs)

• Leverage cloud-based EHR platforms such as Epic, Cerner, and Meditech.
• Utilize advanced clinical review tools to enhance accuracy and workflow.

Communication & Collaboration Tools

Secure Digital Communication

• Secure messaging platforms like Microsoft Teams or Zoom.
• Shared document review using encrypted systems to maintain compliance.

Analytics and Reporting Software

Insights and Trend Monitoring

• Utilize data visualization and documentation audit tools to track trends and provide actionable feedback.

Required Qualifications

Education & Credentials

Certifications and Knowledge Areas

• Registered Nurse (RN), RHIA, or RHIT certification required; CCS or CCDS preferred.
• Strong understanding of operating room procedures and perioperative documentation.
• Knowledge of medical coding, healthcare reimbursement systems, and DRG assignment.

Experience & Skills

Clinical and Technical Proficiency

• Minimum 3 years of recent experience in clinical documentation improvement (CDI), preferably with a surgical or OR background.
• Demonstrated proficiency with EHRs, coding systems (ICD-10, CPT), and clinical terminology.
• Exceptional attention to detail, critical thinking, and communication abilities.

Core Competencies

Strategic Thinking and Agility

• Ability to evaluate complex clinical scenarios and translate them into clear, compliant documentation.
• Excellent coordination skills and a talent for managing diverse cases and priorities remotely.
• Willingness to engage in ongoing learning and adapt to changing industry requirements.

Growth and Leadership Opportunities

Professional Advancement

Career Pathways and Training

• Pursue certification support and leadership development programs.
• Explore cross-training in other specialties, such as cardiology or critical care.
• Potential to grow into senior CDI roles, team leadership, or auditing positions.

Contribution to Organizational Mission

Make a Lasting Impact

• Drive improvements in clinical accuracy, which directly affects patient care quality and institutional reporting.
• Play a key role in upholding ethical healthcare practices through meticulous documentation.
• Help shape future protocols that support transparency, quality improvement, and patient safety.

Compensation and Benefits

• Annual salary: $81,742 (competitive and based on experience).
• Full suite of employee benefits covering medical, dental, vision care, and retirement options.
• Generous paid time off and professional development stipends.
• Flexible work schedule with opportunities for overtime.

Call to Action

Are you ready to make a measurable impact in remote clinical documentation? If you're passionate about accurate health records, patient safety, and operating room integrity, apply now to join a forward-thinking healthcare team. Help elevate the standards of digital health from the comfort of your own workspace—your next career step starts here.