Certified Clinical Documentation Specialist

Job Summary

To enhance the quality of medical record documentation, the full-time remote Certified Clinical Documentation Specialist will facilitate interactions with physicians and staff, conduct medical record reviews, and collaborate with coding professionals to ensure accurate reporting and compliance.

Key responsibilities

• Facilitate improvement in medical record documentation for accurate inpatient coding and APR-DRG assignment
• Conduct medical record reviews and collaborate with inpatient coding professionals
• Reconcile assigned cases and report on CDI program metrics

Required qualifications

• Baccalaureate degree, associate degree, or diploma in nursing, or completion of an AMA-approved Physician Assistant program, or academic requirements for RHIT/RHIA certification
• Current and active Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) certification
• Minimum of 3 years of clinical experience as an RN, PA, or in CDI within a complex acute care setting
• Current RN compact license or PA licensure in the state of residence, if applicable
• Experience with acute inpatient coding for RHIT/RHIA candidates, or relevant clinical experience