Clinical Documentation Specialist IV

Job Summary

To enhance clinical documentation integrity, the full-time remote Clinical Documentation Specialist IV will review medical records, assign medical codes, and support compliance through audits and staff training initiatives.

Key responsibilities:

• Review and analyze a moderate caseload of medical records to ensure accuracy and completeness of clinical documentation
• Integrate processes to improve clinical documentation and support the clinical documentation improvement program
• Conduct staff training and education on clinical documentation 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 a related field
• Minimum four (4) years of experience in nursing, medicine, CDI, inpatient coding, or a directly related field, or seven (7) years of relevant experience without a degree