Nebraska Licensed Clinical Documentation Specialist

Job Summary

To enhance the quality and accuracy of medical record documentation, the part-time Nebraska Licensed Clinical Documentation Specialist will work remotely to facilitate documentation improvement, collaborate with clinicians, and perform concurrent reviews of clinical documentation.

Key responsibilities

• Collaborates with clinicians to ensure accurate clinical documentation in medical records
• Conducts concurrent reviews of clinical documentation to identify missing or understated diagnoses
• Educates internal stakeholders on clinical documentation and coding compliance issues

Required qualifications

• Current RN or LPN licensure from the State of Nebraska or approved compact state
• Minimum of three years of recent clinical experience in an acute care setting
• Registered Health Information Administrator (RHIA) with CCDS or CDIP certification preferred
• Knowledge of ICD-10-CM and clinical coding guidelines
• Ability to work independently and manage time effectively in a remote environment