Clinical Documentation Specialist
Job Summary
Working remotely full-time, the Clinical Documentation Specialist I will provide education to healthcare providers, ensuring accurate documentation of clinical conditions and procedures, while reviewing medical records for compliance with industry standards.
Key responsibilities
- Review and assign appropriate DRG, APC, and HCC codes based on clinical documentation
- Query and educate providers to enhance diagnostic specificity and accurately reflect patient conditions
- Maintain accurate records of review and query activities within the CDI software system
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
- Proficiency in the use of department CDI software
- Ability to utilize reporting functions for developing materials for meetings and presentations
- Commitment to advance education and work towards obtaining ACDIS certification
Complete Job Description
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