State Licensed Clinical Documentation Specialist

Job Summary

Focusing on the accuracy and completeness of inpatient clinical documentation, the remote State Licensed Clinical Documentation Specialist will perform concurrent chart reviews, analyze medical records, and collaborate with healthcare professionals to ensure proper coding and reimbursement.

Key responsibilities

• Analyze medical records to identify and rectify incomplete or inaccurate documentation
• Facilitate clarification of clinical documentation through interaction with physicians and healthcare teams
• Conduct training sessions on documentation best practices and compliance requirements as needed

Required qualifications

• BSN, PA, NP, or Doctorate in a medically related field required
• Minimum of 3 years of experience in a clinical documentation improvement role
• Active RN, MD, DO, NP, or PA license required
• Certification in CCDS and/or CDIP is mandatory; coding credentials (CCS, CPC, CCS-P) are a plus
• Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems