Clinical Documentation Specialist

Job Summary

Providing clinical documentation integrity support remotely, the full-time Clinical Documentation Specialist Audit Coordinator will review and audit medical records to ensure accurate coding and documentation while training end users on CDI systems and workflows.

Key responsibilities

• Conduct clinical documentation chart reviews and query providers to support staffing needs
• Audit medical records and provide feedback for improvement opportunities
• Train end users in CDI system software and deliver documentation education to healthcare team members

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 preferred
• Ability to work independently in a collaborative environment