Clinical Documentation Specialist

Job Summary

To enhance the quality and completeness of clinical documentation, the full-time Clinical Documentation Specialist will work remotely, engaging with physicians and coding staff to ensure accurate medical records and appropriate reimbursement for services rendered.

Key responsibilities

• Facilitates documentation in medical records through interaction with healthcare professionals to improve reimbursement accuracy
• Educates physicians on clinical documentation guidelines and coding opportunities to optimize documentation quality
• Monitors acute care medical records for accuracy and completeness, obtaining necessary information through queries as needed

Required qualifications

• License to practice as a Registered Nurse preferred or credentialed as RHIA, RHIT, or CCS
• Minimum of 1 year of Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience
• CCDS or CDIP credential required
• Experience with concurrent inpatient facility coding and clinical documentation improvement
• Proficiency in evaluating clinical documents for documentation and reimbursement opportunities