State Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation accuracy and compliance, the full-time State Licensed Clinical Documentation Specialist will provide second-level review support for Pediatric Units, collaborating remotely with healthcare professionals to identify documentation gaps and implement improvements.

Key responsibilities

• Conduct detailed chart reviews and perform clinical validation to support documentation improvement efforts
• Collaborate with physicians, nurses, and coders to optimize electronic health record (EHR) use and track/report data for project success
• Provide education to staff and assist in policy development while offering coverage during high-demand periods

Required qualifications

• Current Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) certification
• RN/APRN: Bachelor or Associate Degree in Nursing with a current RN compact license, or PA: completion of an AMA approved PA program with current licensure
• RHIT/RHIA: Completion of academic requirements for RHIT or RHIA certification and Certified Coding Specialist (CCS) certification
• Minimum of 3 years of clinical experience in an acute care setting, with preferred experience as a Clinical Documentation Specialist
• In lieu of specific experience, at least 6 years of CDI experience or relevant clinical experience may be considered