Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist I.

Key Responsibilities

• Determine principal and secondary diagnoses and assign appropriate working DRG based on medical record reviews
• Query and educate providers to enhance diagnostic specificity and accurate admission status
• Maintain documentation compliance and participate in performance improvement and educational activities

Required Qualifications

• High School Diploma/GED or equivalent
• Five years of experience as a clinical nurse in a high acuity department or as an inpatient/outpatient coder, or two years as a Clinical Documentation Integrity Specialist
• Associate's Degree in a healthcare-related field (preferred)
• Registered Nurse (RN) in the current state of employment (preferred)
• Experience with ICD10-CM, CPT, HCC, and HCPCS coding (preferred)