Certified Clinical Documentation Specialist

Job Summary

To enhance clinical documentation integrity, the full-time Certified Clinical Documentation Specialist will perform comprehensive reviews of inpatient medical records, collaborate with healthcare professionals, and provide education on documentation standards while working remotely.

Key responsibilities

• Conduct concurrent reviews of medical records to improve documentation accuracy and completeness
• Develop and manage compliant physician documentation queries in line with industry standards
• Analyze documentation trends and recommend strategies for improvement in clinical representation and quality reporting

Required qualifications

• Graduate of an accredited Nursing program, Medical School, Physician Assistant program, or Nurse Practitioner program
• Three years of Clinical Documentation Integrity experience in an acute care or cancer center environment
• Experience in conducting concurrent clinical documentation reviews and issuing physician queries
• Completion of CDI-focused training through ACDIS, AHIMA, or a similar organization
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) with an active professional license