Lead Clinical Documentation Specialist

Job Summary

To enhance clinical documentation practices, the full-time Lead Clinical Documentation Specialist will manage daily operations, provide real-time clinical reviews, and conduct educational programs, all while working remotely during day shifts.

Key responsibilities

• Oversee daily operations for assigned sites, including staffing, workload balancing, and training on clinical documentation
• Perform real-time clinical reviews for complex cases and ensure appropriate severity of illness and risk of mortality documentation
• Analyze department data for quality and accuracy, identifying trends and conducting educational programs on documentation improvement

Required qualifications

• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Registered Nurse (RN), Doctor of Physical Therapy, or Pharmacist
• RHIA, RHIT, or related clinical/allied health degree
• Minimum of 7 years of inpatient clinical experience
• 2+ years of clinical documentation, coding, case management, or acute-care clinical experience
• CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner), or equivalent required and active