Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist.

Key Responsibilities

• Review medical records for completeness and compliance with regulatory requirements
• Prepare and communicate queries to physicians regarding documentation deficiencies
• Educate healthcare providers on proper documentation and coding practices

Required Qualifications and Education

• Bachelor of Science in Nursing or Health Information Management, or related field
• CCDS, CDIP certification preferred; RN/BSN preferred
• 5 years of Critical Care/Emergency medicine or Medical Surgical experience preferred
• 2-3 years of Clinical Documentation Improvement experience or 5 years of Coding experience preferred
• Familiarity with Medicare reimbursement system and coding structures preferred