State Licensed Clinical Documentation Specialist

Job Summary

To support the accuracy and integrity of clinical documentation, the full-time remote State Licensed Clinical Documentation Specialist will perform concurrent chart reviews, analyze medical records for completeness, and facilitate communication with healthcare providers to ensure appropriate coding and reimbursement.

Key responsibilities

• Analyze medical records to identify incomplete, inconsistent, or inaccurate documentation related to patient diagnoses and treatments
• Perform concurrent chart reviews to ensure clinical documentation accurately reflects the patient's condition and complexity of care
• Collaborate with healthcare professionals to clarify documentation and support accurate coding and compliance with regulatory requirements

Required qualifications

• Minimum of 3 years of experience in a clinical documentation improvement role preferred
• Minimum of 3 years of nursing experience in adult acute care required
• Active RN, MD, DO, NP, or PA license required
• Coding credential (CCS, CPC, CCS-P) is a plus
• Proficient in CDI tools and Microsoft Office Suite