Clinical Documentation Specialist

Job Summary

Utilizing advanced clinical and coding expertise, the full-time remote Clinical Documentation Specialist will ensure the integrity of clinical documentation by conducting thorough record reviews, educating healthcare providers, and collaborating with the healthcare team to support accurate coding and documentation.

Key responsibilities

• Conduct concurrent reviews of patient records to assess the clarity, completeness, and accuracy of clinical documentation
• Communicate discrepancies in documentation to physicians and provide educational sessions on documentation requirements
• Collaborate with multidisciplinary teams to address clinical documentation issues and ensure compliance with coding standards

Required qualifications

• Associate/Diploma Degree in Nursing or Health Information Technology, or an advanced degree in nursing or Physician Assistant, or equivalent experience as an inpatient coder or clinical documentation specialist
• Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Professional (CDIP), or Certified Coding Specialist (CCS) preferred
• Experience in Critical Care, Medical, or Surgical Inpatient Care Nursing, or as an inpatient coder is preferred