State Licensed Clinical Documentation Specialist

Job Summary

Working remotely in a full-time capacity, the State Licensed Clinical Documentation Specialist will conduct concurrent and retrospective reviews of inpatient medical records, focusing on improving documentation quality and supporting accurate coding and compliance.

Key responsibilities

• Initiates physician interactions to clarify ambiguous or missing information in medical records through the physician query process
• Educates physicians and staff on documentation requirements, coding guidelines, and reimbursement policies
• Collaborates with coders and quality improvement teams to resolve documentation issues and enhance coding accuracy

Required qualifications

• Associate's Degree in Nursing (Bachelor's Degree preferred)
• Three to five years of recent clinical work experience in medical-surgical areas, ICU, telemetry, or emergency department
• An active US RN license is required
• Knowledge or experience with electronic medical records (EMR) and CDI platforms