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 ensuring compliance with coding guidelines.

Key responsibilities

• Evaluate clinical documentation to identify opportunities for improvement and engage with physicians for necessary documentation
• Educate healthcare providers on documentation requirements, coding guidelines, and reimbursement policies
• Collaborate 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 experience in medical-surgical, ICU, telemetry, or emergency department settings
• Active US RN license
• Knowledge or experience with electronic medical records (EMR) and Clinical Documentation Improvement (CDI) platforms