Clinical Documentation Specialist

Job Summary

Providing remote clinical documentation integrity support, the full-time Clinical Documentation Specialist Audit Coordinator will review and audit medical records, ensure compliance with documentation standards, and train end users on CDI software and workflows.

Key responsibilities

• Conduct clinical documentation chart reviews and query providers to ensure accurate medical necessity and coding
• Audit medical records and provide feedback to improve documentation practices across the Health Ministry
• Train healthcare team members on CDI system software, standards, and workflow processes

Required qualifications

• Current Registered Nurse License or certifications such as RHIA, RHIT, or CCS
• Certification as a Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred
• Experience in Clinical Documentation Integrity
• Proficiency with databases, spreadsheet software, and presentation software preferred
• Ability to work independently in a collaborative environment