Clinical Document Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Enhance the overall quality and thoroughness of clinical documentation.

• Support adjustments to clinical documentation through proactive communication with physicians and coding personnel.

• Ensure that records accurately represent the diagnoses treated, procedures conducted, and the severity of the patient's illness.

• Engage with physicians regarding any missing, ambiguous, or contradictory medical record documentation via the query process.

• Gather necessary documentation, present opportunities for improvement, and educate physicians on the correct identification of illness severity.

• Work in collaboration with physicians, case managers, coders, and other members of the healthcare team to promote comprehensive inpatient medical record documentation.

• Utilize expertise in complications, co-morbidities, illness severity, mortality risk, case mix, secondary diagnoses, and the impact of procedures on the final DRG.

• Recognize patterns, trends, variances, and opportunities to enhance documentation review and processes.

⛳️ Requirements

• Associate's Degree in Nursing or a healthcare-related field - Required.

• 7 years of acute care nursing experience in lieu of a Bachelor's Degree - Required.

• 2 years of recent inpatient, case management, or emergency department experience - Required.

• Registered Nurse (RN) - State Licensing Board - Preferred.

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Integrity Specialists (ACDIS) - Preferred.

• Bachelor's Degree in Nursing or a healthcare-related field - Preferred.

• Travel requirements: Never or Rarely.

🏝️ Benefits

• Comprehensive benefit offerings for eligible employees.