Clinical Documentation Specialist

Job Summary

Providing essential education to healthcare providers, the full-time Clinical Documentation Specialist will work remotely to ensure accurate documentation of clinical conditions and procedures, while reviewing for correct DRG, APC, and HCC assignments in compliance with industry standards.

Key responsibilities

• Review and query medical records to ensure accurate documentation and coding compliance
• Educate providers on optimal documentation practices to enhance diagnostic specificity and reflect patient conditions accurately
• Maintain records of review and query activities in the CDI software system and meet daily review targets

Required qualifications

• High School Diploma/GED or equivalent
• Five years of experience as a clinical nurse or inpatient/outpatient coder, or two years as a Clinical Documentation Integrity Specialist
• Experience with ICD10-CM, CPT, HCC, and HCPCS coding
• Ability to work under pressure and maintain professionalism in adverse conditions
• Commitment to advancing education and obtaining ACDIS certification