Registered Nurse Clinical Documentation Specialist

Job Summary

To enhance the quality of medical record documentation, the full-time Remote Clinical Documentation Improvement Specialist will conduct concurrent reviews of inpatient medical records, identify documentation improvement opportunities, and collaborate with healthcare providers to ensure accurate coding and compliance with guidelines.

Key responsibilities

• Conduct concurrent reviews of inpatient medical records to identify documentation gaps and improvement opportunities
• Collaborate with healthcare providers to ensure accurate and complete documentation reflecting patient diagnoses and treatments
• Adhere to documentation guidelines set by The Joint Commission, Medicare, and third-party payers to support coding accuracy and quality measures

Required qualifications

• Bachelor's Degree in Nursing
• Current Registered Nurse license
• Minimum of 2 years of relevant experience required; 2-4 years preferred