Senior Clinical Documentation Specialist

Job Summary

To enhance the quality and completeness of clinical documentation, the full-time remote Senior Clinical Documentation Specialist will work directly with providers to ensure accurate representation of patient care and facilitate documentation improvement initiatives.

Key responsibilities:

• Reviews medical records for accuracy and completeness, ensuring diagnoses reflect patient care levels and identifying documentation gaps
• Delivers ongoing education to providers through various communication methods, providing resources for documentation improvement
• Develops compliant queries for providers to clarify documentation and collaborates with coding staff to ensure accurate reimbursement and reporting

Required qualifications:

• Associate's Degree in Nursing, Health Information Management, or a related healthcare field
• Minimum of six years of acute care clinical documentation experience, including knowledge of coding guidelines and healthcare regulations
• Certifications such as CCDS, CDIP, CDEI, or an active RN license
• Proven ability to combine clinical knowledge with coding skills and recognize documentation improvement opportunities
• Proficiency in MS Office and electronic health record systems, with strong analytical and interpersonal skills