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 modifications to clinical documentation through ongoing collaboration with physicians and coding staff.

• Ensure that records accurately reflect treated diagnoses, performed procedures, and the severity of patient illness.

• Engage with physicians regarding missing, ambiguous, or inconsistent documentation via the query process.

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

• Work alongside physicians, case managers, coders, and other healthcare team members to promote complete inpatient medical record documentation.

• Utilize understanding of 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 the documentation review process.

⛳️ Requirements

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

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

• 7 years of acute care nursing experience may substitute for the 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) — ACDIS — Preferred.

• Travel may be required rarely or not at all.

🏝️ Benefits

• Comprehensive benefit offerings for eligible employees.