Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist to ensure the accuracy and integrity of clinical documentation.

Key Responsibilities

• Review clinical records for accuracy related to coding and documentation standards
• Educate and communicate with healthcare providers on documentation requirements and best practices
• Conduct concurrent reviews of patient health records to ensure completeness and clarity of documentation

Required Qualifications

• Associate/Diploma Degree in Nursing or Health Information Technology, or an advanced degree in nursing or Physician Assistant
• 3 or more years of experience as an inpatient coder or clinical documentation specialist in lieu of a degree
• Preferred certifications include Registered Nurse License, RHIA, RHIT, CCS, CCDS, or CDIP
• Experience in Critical Care, Medical or Surgical Inpatient Care Nursing is preferred
• Proficiency in using standard desktop and Windows-based computer systems