Clinical Documentation Specialist

Job Summary

To enhance clinical documentation practices, the full-time Clinical Documentation Specialist will conduct audits, provide education to the CDI team, and support compliance with industry standards while working remotely.

Key responsibilities

• Assess the accuracy and compliance of clinical documentation reviews and provide education to improve practices
• Perform routine and ad hoc audits of CDI queries and documentation for adherence to internal and regulatory standards
• Identify trends and opportunities for improvement in CDI team performance and maintain audit tools and performance metrics

Required qualifications

• Clinical Documentation Prof. credential from the Association of Clinical Documentation Improvement Specialists
• High School diploma with 2 years of experience, or an Associate's/Bachelor's degree, or 4 years of relevant experience
• Expert understanding of CDI best practices and coding principles
• Proficiency with audit tools and EHR systems
• Certified Clinical Documentation Specialist (CCDS) certification preferred