Clinical Documentation Specialist II

Job Summary

To enhance the quality and completeness of clinical documentation, the full-time remote Clinical Documentation Specialist II will collaborate with healthcare providers, assess medical records, and implement documentation improvement strategies while ensuring compliance with healthcare regulations.

Key responsibilities

• Facilitate discussions with providers to improve clinical documentation accuracy and completeness
• Conduct extensive medical record reviews and utilize clinical judgment to assess documentation quality
• Develop and deliver educational content to healthcare staff through virtual meetings and communications

Required qualifications

• Associate's Degree in Nursing, Health Information Management, or a related healthcare field
• Minimum of four years' experience in acute care clinical documentation
• Certification as a Clinical Documentation Specialist (CCDS, CDIP, or CDEI) or active Registered Nurse (RN)
• Proficiency in MS Office, Optum 360 eCAC, and Cerner EHR
• Knowledge of ICD-10-CM, ICD-10-PCS coding, and healthcare regulatory environment