Pennsylvania Licensed Clinical Documentation Specialist

Job Summary

Working from home in Pennsylvania, the full-time salaried Pennsylvania Licensed Clinical Documentation Specialist will act as a liaison between clinical and coding functions, providing education on documentation processes and optimizing clinical documentation to support accurate coding and billing.

Key responsibilities:

• Review inpatient medical records within 24-48 hours of admission to evaluate documentation for accurate diagnosis and procedure assignments
• Formulate queries for missing or unclear documentation and provide ongoing education to healthcare providers on documentation improvement
• Collaborate with interdisciplinary teams to resolve documentation queries and ensure accurate coding prior to patient discharge

Required qualifications:

• Licensed Registered Nurse (Pennsylvania)
• Minimum of three (3) years of nursing experience
• Graduate from a Specialty Training Program in Nursing (required); BSN preferred
• Understanding of Anatomy and Physiology
• Experience with medical records systems and clinical documentation improvement processes