Clinical Documentation Improvement Specialist

Job Summary

Working independently in a full-time remote capacity, the Clinical Documentation Improvement Specialist will review medical records to ensure accurate documentation of clinical treatment and diagnoses, while collaborating with healthcare professionals to enhance documentation practices.

Key responsibilities

• Review medical records for completeness and compliance with regulatory requirements, ensuring accurate documentation of diagnoses and procedures
• Prepare and communicate compliant queries to physicians regarding missing or unclear information in medical records
• Educate and collaborate with healthcare providers to promote correct coding and documentation improvement

Required qualifications

• Bachelor of Science in Nursing or Health Information Management, or related field
• CCDS or CDIP certification preferred, with eligibility to obtain CCDS within 6 months of hire
• A minimum of 2-3 years of Clinical Documentation Improvement experience or 5 years of coding experience preferred
• Working knowledge of Medicare reimbursement systems and coding structures preferred
• Experience in critical care, emergency medicine, or medical surgical settings preferred