Wisconsin Licensed Clinical Documentation Specialist

Job Summary

To enhance clinical documentation standards, the full-time Wisconsin Licensed Clinical Documentation Specialist will communicate with healthcare teams to clarify and obtain necessary documentation while performing in-depth chart reviews remotely during weekdays with no weekend shifts.

Key responsibilities

• Collaborate with healthcare teams to identify and resolve missing or unclear documentation in medical records
• Conduct comprehensive chart reviews to ensure accurate representation of severity of illness and complexity of care
• Provide education and support regarding clinical documentation improvement and coding guidelines

Required qualifications

• Valid Registered Nurse license in Wisconsin
• Minimum of two years of acute care hospital experience
• Experience in critical care, general medical, or surgical nursing
• Familiarity with criteria-based chart reviews and clinical documentation improvement
• Knowledge of ICD code assignment and DRG assignment is preferred