Clinical Documentation Specialist

Job Summary

Working independently in a full-time remote capacity, the Clinical Documentation Specialist will review medical records to ensure accurate documentation of clinical treatment, decisions, and diagnoses while collaborating with healthcare teams to improve documentation quality.

Key responsibilities

• Review medical records for completeness and compliance with regulatory requirements, ensuring accurate documentation of diagnoses and procedures
• Prepare and communicate compliant queries to physicians regarding missing or incomplete information in medical records
• Educate and interact with healthcare providers to promote correct coding and address documentation deficiencies in real-time

Required qualifications

• Bachelor of Science in Nursing, Health Information Management, or a related field
• CCDS or CDIP certification preferred; RN/BSN or RHIA/RHIT with CCS considered
• 5 years of Critical Care/Emergency medicine or Medical Surgical experience preferred
• 2-3 years of Clinical Documentation Improvement experience or 5 years of Coding experience preferred
• Familiarity with Medicare reimbursement systems and coding structures is preferred