Clinical Documentation Specialist

Job Summary

Utilizing advanced clinical and coding expertise, the full-time Clinical Documentation Specialist will ensure the integrity of clinical documentation through extensive record review and education, while working remotely to support healthcare teams in achieving accurate documentation for patient care.

Key responsibilities

• Conduct concurrent reviews of patient records to ensure clarity, completeness, and accuracy of clinical documentation
• Educate physicians and healthcare team members on documentation requirements and communicate discrepancies as needed
• Collaborate with multidisciplinary teams to address clinical documentation issues and promote performance improvement activities

Required qualifications

• Associate/Diploma Degree in Nursing, Health Information Technology, or an advanced degree in nursing or Physician Assistant
• Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Professional (CDIP), or Certified Coding Specialist (CCS) preferred
• Three or more years of experience as an inpatient coder or clinical documentation specialist in lieu of a college degree
• Experience in Critical Care, Medical, or Surgical Inpatient Care Nursing, or as an inpatient coder is preferred