Clinical Documentation Improvement Specialist

Job Summary

To enhance clinical documentation practices, the full-time Clinical Documentation Improvement Specialist will remotely review patient medical records, ensuring accurate representation of diagnoses and treatments while collaborating with healthcare providers and coding professionals.

Key responsibilities

• Review inpatient medical records for accuracy and compliance, ensuring documentation reflects the patient's severity of illness and intensity of services
• Generate queries to clarify physician documentation and resolve any conflicting or ambiguous information in medical records
• Collaborate with HIM Leadership and provide educational support to healthcare staff to improve clinical documentation processes

Required qualifications

• 3-5 years of relevant experience in clinical documentation improvement
• High School diploma or GED required; Bachelor's Degree required
• Bachelor's of Science in Nursing preferred
• Certified Clinical Documentation Specialist Certification preferred
• Registered Nurse license in any state preferred