Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist-Remote.

Key Responsibilities

• Conducts concurrent reviews of patient records to ensure clarity, completeness, and accuracy of clinical documentation
• Communicates documentation discrepancies to physicians and provides educational sessions on documentation requirements
• Collaborates with healthcare team members to address clinical documentation issues and participates in performance improvement activities

Required Qualifications

• Associate/Diploma Degree in Nursing, Health Information Technology, or an advanced degree in nursing or Physician Assistant
• In the absence of a degree, a minimum of 3 years' experience as an inpatient coder or clinical documentation specialist is required
• Certifications such as RHIA, RHIT, CCDS, CDIP, or CCS are considered in lieu of an RN
• Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, or as an inpatient coder is preferred