Clinical Documentation Specialist

Job Summary

Working remotely on a per diem basis, the Clinical Documentation Specialist will review medical records to ensure accurate documentation of clinical treatment and diagnoses while collaborating with healthcare teams to improve documentation practices.

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 healthcare providers on documentation improvement and coding compliance through real-time interventions

Required qualifications:

• Bachelor of Science in Nursing, Health Information Management, or a related field
• CCDS or CDIP certification preferred, with the requirement to obtain CCDS within six months for eligible candidates
• 5 years of experience in Critical Care/Emergency medicine or Medical Surgical settings preferred
• 2-3 years of Clinical Documentation Improvement experience or 5 years of Coding experience preferred
• Familiarity with Medicare reimbursement systems and coding structures preferred