Clinical Documentation Specialist

Job Summary

To support clinical documentation improvement efforts, the full-time Clinical Documentation Specialist will conduct comprehensive chart reviews, collaborate with healthcare professionals to ensure accurate documentation, and initiate physician queries as needed, all while working remotely.

Key responsibilities

• Perform daily, concurrent reviews of inpatient records to ensure accurate documentation for coding compliance
• Collaborate with coders and other healthcare staff to identify documentation gaps and initiate queries for clarification
• Update and maintain working DRG assignments based on documentation and physician responses

Required qualifications

• University degree with 2-4 years of relevant experience; graduate-level education may be required for some roles
• Current RN, MD, or equivalent certification (MBBS), or CCS credential
• 4+ years of direct patient care experience in inpatient settings, critical care, or strong med-surg experience
• 2+ years of prior clinical documentation improvement (CDI) experience
• Familiarity with encoder and DRG assignment, along with knowledge of official coding guidelines