New York Licensed Clinical Document Specialist

Job Summary

To enhance clinical documentation practices, the full-time New York Licensed Clinical Document Specialist will facilitate improvements through interaction with healthcare teams, ensuring compliance with documentation standards and maximizing revenue, while working remotely.

Key responsibilities

• Facilitates modifications in clinical documentation to support accurate medical condition representation for inpatient encounters
• Provides oversight of clinical documentation processes and communicates with physicians to ensure complete and accurate medical records
• Presents findings to stakeholders and educates peers on documentation improvement and reimbursement opportunities

Required qualifications

• Bachelor's degree in Nursing (BSN) or relevant clinical discipline with 5 years of inpatient clinical experience required
• Current New York State license as a Registered Nurse, Nurse Practitioner, Physician Assistant, or Medical Doctor required
• Clinical Documentation Specialist (CDS) or Clinical Documentation Improvement Professional (CDIP) certification preferred
• Knowledge of complex disease processes necessary
• Prior experience with EPARC, eRecord, HDM, and SharePoint preferred