Remote RN Clinical Documentation Specialist

Job Summary

Working remotely in a full-time capacity, the RN Clinical Documentation Specialist will review medical records to enhance the accuracy of clinical documentation, ensuring it reflects the patient's severity of illness and risk of mortality while collaborating with healthcare professionals.

Key responsibilities

• Review inpatient medical records and facilitate modifications to clinical documentation through interaction with physicians and nursing staff
• Develop and implement educational plans for medical and ancillary staff on documentation improvement
• Analyze clinical information to identify gaps in physician documentation and ensure compliance with regulatory standards

Required qualifications

• Active RN or PA clinical license; BSN preferred
• CCDS or CDIP certification is a plus
• 3 to 5 years of varied hospital clinical experience, with a preference for critical care or medical surgical backgrounds
• Ability to pass a written clinical competency exam
• Knowledge of regulatory environments, including Medicare Part A and Part B, is preferred