Clinical Documentation Specialist RN Licensed

Job Summary

Working remotely in a full-time capacity, the Clinical Documentation Specialist RN Licensed will facilitate the improvement of medical record documentation quality, ensuring accurate inpatient coding and collaborating with healthcare professionals to achieve optimal documentation outcomes.

Key responsibilities

• Conduct medical record reviews and collaborate with inpatient coding professionals to enhance documentation accuracy
• Engage with physicians and staff to obtain necessary documentation for coding and reporting purposes
• Monitor and report on CDI program metrics and reconcile assigned cases as required

Required qualifications

• Baccalaureate degree, associate degree, or diploma in nursing, or completion of an AMA-approved Physician Assistant program, or RHIT/RHIA academic requirements
• Current RN compact license or state-specific RN license, or current PA licensure and board certification
• Certification as a Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP)
• A minimum of 3 years of clinical experience as an RN, PA, or in CDI in an acute care setting
• Experience in acute inpatient coding or CDI is preferred for RHIT/RHIA candidates