Clinical Documentation Specialist

Job Summary

To support the mission of extending care, the full-time Clinical Documentation Specialist will examine medical records for accuracy and completeness, detect inconsistencies, and ensure compliance with coding standards while working remotely during day shifts.

Key responsibilities

• Examine medical records to ensure accurate and complete documentation reflective of the patient's clinical status
• Collaborate with the coding/revenue cycle team to verify clinical documentation supports correct coding for reimbursement
• Provide guidance and education on documentation best practices to physicians and clinical staff

Required qualifications

• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Registered Nurse (RN), Pharmacist, or Doctor of Physical Therapy
• RHIA, RHIT, or related clinical/allied health degree
• Minimum of 5 years inpatient clinical experience
• 2+ years of clinical documentation, coding, case management, or acute-care clinical experience
• CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner), or equivalent required or within 90 days