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, collaborate with healthcare providers, and educate staff on documentation practices in a remote setting.

Key responsibilities:

• Facilitate modifications to clinical documentation through concurrent chart reviews and interactions with clinicians
• Educate physicians and clinical staff on documentation opportunities and coding issues
• Utilize client technology to track documentation and ensure accuracy in coding and DRG assignments

Required qualifications:

• Licensed as a Registered Nurse with an Associate Degree in Nursing (ADN) or Bachelor's degree in Nursing (BSN), or an MD
• At least three years of recent acute care nursing experience, preferably in ICU or ED
• For HIM professionals, credentialed as RHIA, RHIT, CPC, or CCS with experience in ICD-10 coding
• Minimum of three years of clinical coding and/or auditing experience in a hospital environment
• Strong knowledge of clinical documentation guidelines and computer literacy required