Clinical Documentation Specialist

Job Summary

Utilizing clinical and coding expertise, the full-time Clinical Documentation Specialist will ensure the integrity of clinical documentation by conducting record reviews, educating healthcare providers, and formulating compliant queries, all while working remotely.

Key responsibilities

• Conduct concurrent reviews of patient health records to ensure accuracy and completeness of clinical documentation
• Communicate with and educate healthcare team members on clinical documentation best practices
• Formulate compliant clarifications and queries following established documentation integrity procedures

Required qualifications

• Associate/Diploma Degree in Health Information Technology or an advanced degree in nursing or Physician Assistant; or three years of relevant experience in lieu of a degree
• Preferred certifications include RN, RHIA, RHIT, CCS, CCDS, or CDIP
• Experience in critical care or inpatient care nursing as an RN, PA, NP, or APN preferred
• Proficiency in using standardized desktop and Windows-based computer systems with data entry skills of at least 30 wpm
• Strong critical thinking, prioritization, and organizational skills