Clinical Documentation Specialist

Job Summary

To enhance clinical documentation integrity, the full-time remote Clinical Documentation Specialist IV will review medical records for accuracy, assign medical codes, and support the CDI program while ensuring compliance with regulatory standards.

Key responsibilities:

• Review a moderate caseload of medical/health records to ensure accuracy and completeness of clinical documentation
• Integrate processes to improve clinical documentation and facilitate documentation issue resolution
• Conduct staff training and education on clinical documentation improvement and coding standards

Required qualifications:

• Minimum two (2) years of experience in an inpatient acute care or clinical setting
• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or a related field AND four (4) years of relevant experience, or seven (7) years of experience in a directly related field