Certified Clinical Document Specialist

Job Summary

To support a growing healthcare organization, the full-time remote Certified Clinical Document Specialist will perform concurrent reviews of inpatient acute-care medical records, ensuring accurate documentation of clinical conditions and services provided.

Key responsibilities:

• Conduct approximately 15-16 chart reviews daily, identifying documentation discrepancies and developing compliant provider queries
• Collaborate with clinical staff to enhance documentation accuracy and completeness, impacting quality measures and reimbursement
• Maintain up-to-date knowledge of clinical criteria, coding guidelines, and CDI best practices while meeting departmental productivity and quality expectations

Required qualifications:

• Minimum of 3 years of experience as a Clinical Documentation Specialist in an inpatient acute-care environment
• Active certification as a CCS, CDIP, or CCDS at the time of submission
• Strong understanding of inpatient coding concepts and clinical validation principles
• Experience with Optum CAC and knowledge of ICD-10-CM and ICD-10-PCS preferred
• Healthcare-related education preferred, with relevant experience considered in lieu of formal education