Clinical Documentation Specialist

Job Summary

Working remotely full-time, the Clinical Documentation Specialist I will provide education to healthcare providers, ensure accurate documentation of clinical conditions and procedures, and review for correct coding assignments while adhering to compliance standards.

Key responsibilities

• Review medical records to determine principal and secondary diagnoses and assign appropriate DRG
• Query and educate providers to enhance diagnostic specificity and ensure accurate representation of patient conditions
• Maintain documentation compliance and meet daily review and query targets using CDI software

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
• Proficient in the use of department CDI software
• Ability to utilize reporting functions for meetings and presentations
• Knowledge of inpatient and outpatient payment methodologies