Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Improvement Specialist (Remote).

Key Responsibilities

• Examine medical records for accuracy and completeness, ensuring they reflect the patient's clinical status
• Detect and address inconsistencies or missing information in documentation, collaborating with providers as needed
• Provide guidance and education on documentation best practices to improve overall documentation quality

Required Qualifications and Education

• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Registered Nurse (RN), Pharmacist, or Doctor of Physical Therapy
• RHIA, RHIT, or a related clinical/allied health degree
• Minimum of 5 years of inpatient clinical experience
• 2+ years of experience in clinical documentation, coding, or acute-care clinical roles
• CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner), or equivalent required within 90 days