Clinical Documentation Specialist III

Job Summary

To enhance the quality and completeness of clinical documentation, the full-time Clinical Documentation Specialist III will facilitate modifications through collaboration with healthcare professionals, ensure compliance with regulations, and educate staff on documentation practices while working remotely.

Key responsibilities

• Facilitates improvement in medical record documentation quality through concurrent auditing and evaluation
• Analyzes clinical status and treatment plans to identify gaps in documentation and ensures appropriate reimbursement
• Educates nursing staff and coding personnel on compliant documentation and reimbursement issues while mentoring junior staff

Required qualifications

• RN/BSN or related healthcare professional preferred, with experience in med-surgical, critical care, or emergency care
• Minimum of 5 years of experience as a healthcare professional, with a focus on relevant clinical areas
• Expert knowledge of ICD-10 CM/PCS and current Medicare and Medicaid regulations regarding clinical documentation and billing compliance
• Eligibility for CAC, CCS, or CCDS certifications is preferred