Clinical Documentation Specialist

Sigma Systems

Remote Clinical Documentation Specialist responsible for quality of medical records and patient outreach in home health. Interacting with healthcare providers and coordinating care based on CMS guidelines.

Posted 5/27/2026contractRemote • Texas • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Facilitating improvement in the overall quality and completeness of the medical record documentation
Providing support and expertise through comprehensive assessment and review of inpatient medical records
Ensuring accurate DRG assignment and obtaining appropriate documentation through interaction with physicians, patient caregivers, and health information management coding staff
Monitoring home health patients to ensure they meet CMS criteria for services
Proactive outreach to patients and making recommendations to primary care providers
Facilitating communication and coordinating care with healthcare providers and caregivers
Creating positive relationships with home health agencies as well as primary care clinicians

Requirements

What you’ll need

Bachelor's Degree in Nursing preferred
Foreign or domestic Medical School Graduate (license not required), OR Graduate from a Physician's Assistant or RN Program
3-5 years of clinical experience required
2 years of home health experience preferred
2-3 years of managed care and/or care management experience preferred
An RN license in the state of employment or compact is required

Benefits

Comp & perks

Health insurance
401(k) matching
Flexible work hours
Paid time off

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical record documentationDRG assignmentpatient assessmentclinical experiencehome health experiencemanaged carecare management

Soft Skills

communicationrelationship buildingcoordinationproactive outreach

Certifications

RN license