Clinical Documentation Specialist (CDS)

Job Summary

Seeking an experienced Clinical Documentation Specialist (CDS) for a full-time remote position, responsible for enhancing documentation integrity in inpatient care through record review, education, and consultation while ensuring compliance with documentation standards.

Key responsibilities

• Conduct extensive reviews of patient health records to ensure clarity, completeness, and accuracy of clinical documentation
• Communicate and educate healthcare providers on documentation requirements and monitor engagement for improvement
• Collaborate with coding staff to ensure comprehensive documentation of diagnoses and resolve discrepancies in a professional manner

Required qualifications

• Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or an advanced degree in a medical field
• Current Registered Nurse License, RHIA, RHIT, CCS, or licensure as a PA/NP/APN
• Preferred Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP)
• Two years of experience in Critical Care, Medical or Surgical Inpatient Care Nursing, or as an inpatient coder