Clinical Documentation Specialist

Job Summary

A company is looking for a Senior Clinical Documentation Improvement Specialist.

Key Responsibilities

• Conduct concurrent and retrospective reviews of inpatient medical records to ensure accuracy and completeness of clinical documentation
• Collaborate with inpatient care providers to maintain compliant and consistent documentation reflecting the patient's clinical scenario
• Identify opportunities for improvement in documentation to accurately represent Severity of Illness (SOI) and Risk of Mortality (ROM)

Required Qualifications

• Education: RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP
• Experience: Minimum of 1 year in acute care inpatient nursing or inpatient coding or HIM
• Strong clinical knowledge and ability to interpret clinical data
• Ability to work independently and manage workflow to meet deadlines
• Preferred: 3 years in nursing, inpatient coding, or HIM role in an acute hospital setting