Clinical Documentation Specialist
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Job Summary
Providing education to healthcare providers, the full-time Clinical Documentation Specialist will work remotely from 8:00 a.m. to 4:00 p.m. to ensure accurate documentation of clinical conditions and procedures, review for correct DRG and HCC assignment, and maintain compliance with industry standards.
Key responsibilities
- Review medical records to determine principal and secondary diagnoses and assign appropriate working DRGs
- Query and educate providers to enhance diagnostic specificity and ensure accurate reflection of patient conditions
- Maintain comprehensive records of review and query activity within the CDI software system while meeting daily targets
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
- ICD10-CM, CPT, HCC, and HCPCS coding experience
- Experience in ICU and surgical settings
- Familiarity with EPIC, 3M, and Microsoft systems
Complete Job Description
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