A partner of Insight Global is seeking a highly skilled and detail-oriented Clinical Documentation Specialist (CDS) with extensive experience in hospital-based care and orthopedic surgery. The ideal candidate will possess deep knowledge of medical coding, billing practices, and clinical terminology, and will play a critical role in ensuring the accuracy, completeness, and compliance of clinical documentation to support optimal patient care and reimbursement.
Review inpatient and outpatient clinical documentation for orthopedic surgery and hospital services to ensure accuracy, clarity, and specificity.
Collaborate with physicians, surgeons, and clinical staff to clarify documentation and ensure alignment with coding and billing requirements.
Apply advanced knowledge of ICD-10-CM, CPT, and HCPCS Level II coding systems to support accurate coding and reimbursement.
Conduct concurrent and retrospective reviews of medical records to identify documentation gaps and opportunities for improvement.
Ensure documentation supports medical necessity, severity of illness, risk of mortality, and quality metrics.
Assist in the development and delivery of provider education on documentation best practices and regulatory compliance.
Stay current with changes in coding guidelines, payer requirements, and healthcare regulations (e.g., CMS, HIPAA).
Participate in audits, quality improvement initiatives, and compliance reviews as needed.
We are a company committed to creating inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity employer that believes everyone matters. Qualified candidates will receive consideration for employment opportunities without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, disability, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to
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Associates or Bachelors degree in Health Information Management, Nursing, or related field.
Minimum 5 years of experience in clinical documentation improvement, with a strong background in hospital and orthopedic surgery coding.
Proficiency in EHR systems (e.g., Epic, Cerner) and coding software
Excellent communication and interpersonal abilities.
High attention to detail and accuracy.
Ability to work independently and collaboratively in a fast-paced environment.
Commitment to confidentiality and ethical standards.
Clinical background (e.g., RN, PA, or other licensed healthcare professional).
Certification in one or more of the following: CCDS, CDIP, RHIA, RHIT, CCS, CPC.
Experience with orthopedic-specific procedures and terminology.
Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.