RN Clinical Documentation Specialist

Job Summary

Working remotely on a per diem basis, the Clinical Documentation Specialist will improve the quality and completeness of provider-based clinical documentation by reviewing patient records, assisting providers, and delivering education on documentation improvement.

Key responsibilities

• Review patient records to ensure accuracy regarding severity of illness and level of services rendered
• Collaborate with providers, coders, and patient care team members to enhance comprehensive patient documentation
• Formulate and respond to documentation clarification requests while developing educational materials for providers

Required qualifications

• Associate degree in Health Information Management or related field
• 1-2 years of inpatient coding experience
• RN with active state licensure OR Certification: RHIA/RHIT, CCS, CDIP, CCDS