State Licensed Clinical Documentation Specialist

Job Summary

To support the accuracy of clinical documentation, the fully remote State Licensed Clinical Documentation Specialist will review medical records for compliance, collaborate with healthcare professionals, and identify documentation improvement opportunities.

Key Responsibilities

• Review and evaluate medical record documentation for completeness, accuracy, and compliance
• Collaborate with physicians, nurses, and coding professionals to ensure appropriate clinical documentation
• Identify opportunities for documentation improvement to support coding accuracy, reimbursement, and clinical outcomes

Required Qualifications

• 2 years of clinical documentation improvement (CDI) experience
• Registered Nurse (RN) certification
• Knowledge of ICD-10-CM, MS-DRGs, coding guidelines, and compliance standards
• Proficiency in MS Office, email, VPNs, and video conferencing tools
• Experience using 3M and Epic preferred but not required