Clinical Documentation Specialist IV

Job Summary

Working remotely in a full-time capacity, the Clinical Documentation Specialist IV will review medical records to ensure the accuracy and completeness of clinical documentation, assign medical codes and DRGs, and support the clinical documentation improvement program while collaborating on staff training and regulatory compliance initiatives.

Key responsibilities:

• Review a moderate caseload of medical records to promote documentation accuracy and completeness
• Integrate processes to enhance clinical documentation improvement and resolve documentation issues
• Conduct staff training and education on clinical documentation standards and requirements

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 AND minimum four (4) years of relevant experience, or minimum seven (7) years of experience in a directly related field