Clinical Documentation Specialist IV

Job Summary

Working remotely in a full-time capacity, the Clinical Documentation Specialist IV will review medical records to ensure accuracy and completeness, assign medical codes, and enhance clinical documentation improvement programs while supporting regulatory compliance and conducting staff training.

Key responsibilities:

• Review a moderate caseload of medical/health records to promote accurate clinical documentation and assign medical codes
• Integrate processes to improve clinical documentation and resolve documentation issues through collaboration with team members
• Conduct staff training and education on clinical documentation improvement, coding standards, and regulatory compliance

Required qualifications:

• Minimum two (2) years of experience in an inpatient acute care or clinical setting
• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or related field
• Minimum four (4) years of experience in nursing, medicine, CDI, inpatient coding, quality review, case management, or a directly related field, or a minimum of seven (7) years of relevant experience