Clinical Documentation Specialist II, MD Licensed

Job Summary

To enhance the quality and completeness of medical record documentation, the full-time Clinical Documentation Specialist II, MD Licensed will work remotely, focusing on medical record review, collaboration with coding professionals, and reporting CDI program metrics.

Key responsibilities

• Facilitate improvements in medical record documentation for accurate coding and APR-DRG assignment
• Collaborate with physicians and staff to obtain appropriate documentation
• Perform reconciliations of assigned cases and accurately report CDI program metrics

Required qualifications

• Baccalaureate degree, associate degree, or diploma in nursing, or completion of an AMA approved Physician Assistant program, or academic requirements for RHIT/RHIA certification
• Current RN compact license or PA licensure in the state of residence
• Certification as a Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP)
• Minimum of 3 years of clinical experience in a complex acute care setting or CDI experience
• Successful completion of academic requirements for Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification