Clinical Documentation Specialist

Job Summary

Working remotely in a full-time capacity, the Clinical Documentation Specialist will conduct comprehensive secondary clinical chart reviews, collaborate with healthcare teams to ensure accurate documentation, and manage daily inpatient record reviews for compliant coding.

Key responsibilities

• Perform comprehensive secondary clinical chart reviews to identify documentation clarification opportunities
• Conduct daily, concurrent reviews of inpatient records to ensure accurate physician documentation at discharge
• Initiate compliant physician queries when documentation is ambiguous or missing

Required qualifications

• Bachelor's degree
• One of the following: RN, MD, or MD Equivalent (MBBS)
• 4+ years of experience providing direct patient care in inpatient settings
• 2+ years of prior Clinical Documentation Improvement (CDI) experience
• Familiarity with encoder and DRG assignment