Clinical Documentation Specialist

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

📋 Description

• Facilitate enhancements in the quality, completeness, and accuracy of clinical documentation to bolster patient care and reimbursement outcomes.

• Analyze clinical records to pinpoint documentation opportunities concerning severity of illness, risk of mortality, and coding precision.

• Assign working DRGs for inpatient admissions and assist in accurate code assignment.

• Collaborate with physicians, Nurse Case Managers, and multidisciplinary care teams to ensure comprehensive and precise clinical documentation.

• Query providers to clarify incomplete, conflicting, or ambiguous documentation using established processes.

• Conduct clinical record abstraction and data collection to aid reimbursement, quality initiatives, and outcome reporting.

• Educate physicians and care teams on documentation standards, coding updates, MS-DRG changes, and coding guidelines.

• Guarantee the accuracy and integrity of medical record data prior to billing and claims submission.

• Work in partnership with Patient Accounting and coding teams to resolve issues related to reimbursement and documentation.

• Support quality management and continuous improvement initiatives through data analysis, education, and efforts to ensure documentation integrity.

⛳️ Requirements

• Associate’s or Bachelor’s degree in Health Information Management and/or a Certified Coding Specialist (CCS) credential.

• A minimum of two years of inpatient clinical coding experience or successful completion of a coding competency assessment.

• CCS, CDIP, or CCDS certification is required.

• Familiarity with concurrent coding models is strongly preferred.

• Proficiency with Encoder/Grouper technology and robust computer skills.

• Understanding of clinical documentation improvement (CDI) principles and coding compliance requirements.

• Capability to effectively communicate and collaborate with physicians and interdisciplinary teams.

• Strong analytical, critical thinking, and problem-solving abilities.

• Commitment to upholding data integrity, coding accuracy, and regulatory compliance.

• Nursing degree and/or registered nurse experience is preferred.

🏝️ Benefits

• Comprehensive Benefits