State Licensed Clinical Document Specialist

Job Summary

To enhance clinical documentation quality, the full-time State Licensed Clinical Document Specialist will conduct concurrent chart reviews, educate healthcare staff on documentation practices, and collaborate with coding teams while working remotely.

Key responsibilities:

• Facilitate modifications to clinical documentation through extensive concurrent reviews and interactions with healthcare providers
• Educate physicians and clinical staff on documentation, coding, and reimbursement issues to improve overall documentation quality
• Utilize client technology to track documentation notes, assign Working DRG, and ensure accurate coding of diagnoses

Required qualifications:

• Licensed as a Registered Nurse (ADN or BSN) or an MD, or credentialed as RHIA, RHIT, CPC, or CCS with experience in ICD-10 coding
• At least three years of recent acute care nursing experience or clinical coding/auditing experience in a hospital environment
• Strong knowledge of clinical documentation guidelines and coding regulations
• Proficiency in computerized hospital/health information management systems
• Excellent communication and organizational skills, with the ability to work collaboratively and independently