State Licensed Clinical Documentation Specialist

Job Summary

Providing clinically based concurrent and retrospective reviews of inpatient medical records, the part-time State Licensed Clinical Documentation Specialist will evaluate documentation and utilization of acute care services to ensure accurate physician documentation and compliance for reimbursement.

Key responsibilities

• Conduct concurrent and retrospective reviews of inpatient medical records to assess documentation quality and compliance
• Facilitate appropriate physician documentation to reflect patient severity of illness and risk of mortality
• Collaborate with external payers and regulatory agencies to meet documentation requirements and improve quality of care outcomes

Required qualifications

• Bachelor's degree in Nursing or Health Information Management, or equivalent experience
• Current RN or CCS license; CCDS or CDIP preferred
• Minimum of 6 years of related clinical experience, including inpatient case management or coding
• Strong knowledge of care delivery documentation systems and medical record documentation
• Ability to work independently in a time-oriented environment and maintain effective physician communication