SaidGig

Clinical Documentation Specialist

$55–$80/hr

RemoteContracthealthcare
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About this role

Role Overview

As a Clinical Documentation Expert, you will play a crucial role in advancing clinical documentation through the development of long-horizon documentation tasks. These tasks will reflect your existing expertise and will be evaluated using a deterministic rubric that assesses agent performance against verifiable ground truth. You will focus on creating scenarios that require checkable answers, avoiding open-ended essays or subjective judgments.

Key Responsibilities
  • Develop encounter documentation tasks, including SOAP notes, H&Ps, and progress notes, ensuring all required elements and source-supported findings are included.
  • Create transitions of care documentation, such as discharge summaries with a specified field list and medication reconciliation linked to source data.
  • Formulate CDI queries based on rule-defined documentation gaps, ensuring correct query framing is utilized.
  • Engage in challenging tasks that require sustained focus and attention to detail.
Qualifications
  • Minimum of 2 years of experience in a documentation-heavy role such as medical scribe, CDI specialist, RN, NP, or PA.
  • Proficiency in one or more areas: SOAP or H&P authoring, CDI query practice, discharge summary construction, or EHR documentation workflows (Epic, Cerner).
  • Ability to read and produce clinical artifacts, including SOAP notes, H&Ps, discharge summaries, and CDI queries.
  • Strong written communication skills, with the ability to articulate reasoning clearly and encode it into deterministic rubrics.
  • Must be located in the United States.
Compensation

The hourly rate for this position ranges from $55 to $80, depending on your domain expertise and prior experience. High-performing contributors will have opportunities for promotion based on the quality and throughput of their tasks.

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