Clinical Documentation Specialist

A company is looking for a Clinical Documentation Specialist-Remote.

Key Responsibilities

Conducts concurrent reviews of patient records to ensure clarity, completeness, and accuracy of clinical documentation

Communicates documentation discrepancies to physicians and provides educational sessions on documentation requirements

Collaborates with healthcare team members to address clinical documentation issues and participates in performance improvement activities

Required Qualifications

Associate / Diploma Degree in Nursing, Health Information Technology, or an advanced degree in nursing or Physician Assistant

In the absence of a degree, a minimum of 3 years' experience as an inpatient coder or clinical documentation specialist is required

Certifications such as RHIA, RHIT, CCDS, CDIP, or CCS are considered in lieu of an RN

Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, or as an inpatient coder is preferred