Clinical Documentation Specialist

Job Summary

Providing education to healthcare providers, the full-time Clinical Documentation Specialist will work remotely from 8:00 a.m. to 4:00 p.m. to ensure accurate documentation of clinical conditions and procedures, review for proper coding assignments, and maintain compliance with industry standards.

Key responsibilities

• Review medical records to determine principal and secondary diagnoses, and assign appropriate working DRGs
• Query and educate providers to enhance diagnostic specificity and ensure accurate reflection of patient conditions
• Maintain documentation and query activity records within the CDI software system while meeting daily review and query targets

Required qualifications

• High School Diploma/GED or equivalent
• Five years of experience as a clinical nurse or inpatient/outpatient coder, or two years as a Clinical Documentation Integrity Specialist
• Associate's Degree in a healthcare-related field (preferred)
• ICD10-CM, CPT, HCC, and HCPCS coding experience
• Experience with EPIC, 3M, and Microsoft Office (preferred)