State Licensed Clinical Documentation Specialist

Job Summary

To support the accuracy and completeness of patient records, the full-time Remote State Licensed Clinical Documentation Specialist will perform clinical documentation improvement activities, collaborate with healthcare providers, and ensure compliance with regulatory standards.

Key responsibilities

• Analyze inpatient clinical records to identify opportunities for improving documentation accuracy and ensure assigned codes reflect patient severity
• Provide education and training to healthcare providers on documentation improvement and lead physician education initiatives
• Utilize CDI software to track activities, report impact metrics, and ensure compliance with updated coding and documentation standards

Required qualifications

• Associate Degree in Nursing or a comparable clinical field required
• 3-5 years of acute care hospital nursing experience required
• 3-5 years of experience in clinical documentation improvement or health information management preferred
• Registered Nurse state licensure or comparable clinical license required
• Familiarity with regulatory standards and quality metrics related to clinical documentation preferred