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 healthcare team members on CDI software and processes.

Key responsibilities

• Conduct clinical documentation chart reviews and communicate with healthcare providers regarding documentation accuracy
• Audit medical records and provide feedback to improve documentation practices and coding accuracy
• Train end users on CDI system software and develop educational content related to documentation and coding guidelines

Required qualifications

• Current Registered Nurse License, RHIA, RHIT, or CCS certification
• 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
• Ability to operate independently in a collaborative environment