Clinical Documentation Specialist (NM Licensed)

Job Summary

A company is looking for a Clinical Documentation and Compliance Specialist.

Key Responsibilities

• Analyze clinical documentation for completeness, coding accuracy, and compliance
• Perform concurrent reviews of medical records for inpatient admissions and document findings
• Collaborate with medical and nursing staff to improve chart documentation quality

Required Qualifications

• Associates degree in Nursing with 5 years clinical experience or Bachelor's degree with 2 years CDI experience
• CCDS certification required within 3 years of employment
• Working knowledge of medical terminology, ICD-10, CPT, HCPCS, and DRG
• Up-to-date clinical skills and knowledge of pathology and pharmacology
• Experience with database, spreadsheet, and word processing software