Illinois Licensed Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist, First Reviewer.

Key Responsibilities

• Conducts initial and follow-up reviews of patient records to assign diagnoses and procedures for accurate DRG assignments
• Queries physicians for additional documentation and educates healthcare providers on clinical documentation improvement
• Collaborates with coding professionals to resolve discrepancies and supports accurate DRG, SOI, and ROM assignments

Required Qualifications, Training, and Education

• Graduate of an accredited nursing school, PA, NP, or medical school, or Associate's degree with CCDS certification
• Two years of experience in an acute care setting or relevant experience
• Certified Clinical Documentation Specialist (CCDS) or relevant professional license (e.g., RN, PA, Physician)
• Ability to perform physical tasks such as lifting and data entry
• Knowledge of clinical documentation guidelines and coding regulations