Clinical Documentation Specialist

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

📋 Description

• Examine inpatient medical records to pinpoint documentation opportunities that reflect the severity of illness and mortality risk.

• Determine principal and secondary diagnoses, comorbidities, complications, CCs, and MCCs utilizing clinical criteria.

• Concurrently assign DRGs and capture documentation specificity that supports diagnoses and clinical indicators.

• Participate in multidisciplinary rounds and engage with providers.

• Submit verbal, electronic, or written queries for clarification or additional documentation.

• Elevate unresolved queries and liaise with physician advisors.

• Work in collaboration with HIM coding staff to ensure precise clinical documentation and rectify coding discrepancies.

• Implement clinical documentation requirements, coding guidelines, DRG assignment standards, compliance standards, and ICD-10 requirements.

• Take part in documentation or query audits and support interdepartmental compliance initiatives.

• Assist with education for providers and departments, including courses, printed materials, and presentations.

⛳️ Requirements

• Bachelor's Degree in Nursing.

• Valid RN (Registered Nurse) license in the State of Ohio issued by the Ohio Board of Nursing.

• At least 5 years of experience in an adult inpatient medical/surgical or critical care environment.

• Strong critical reasoning skills for clinical decision-making and problem-solving.

• Proficiency in data interpretation.

• Flexible, positive attitude with excellent interpersonal and communication skills.

• Ability to collaboratively share information with physicians and other staff members.

• Strong organizational and computer skills.

• Extensive knowledge of clinical documentation requirements, coding guidelines, DRG assignment, and clinical conditions and procedures.

• Awareness of compliance standards, AHIMA Standards of Ethical Coding guidelines, hospital quality metrics, and healthcare regulations.

• Proficient in ICD-10 documentation requirements.

• Familiarity with Microsoft Word, Excel, and facility-based EHR applications.

🏝️ Benefits

• Full-time schedule with 40 hours scheduled weekly.

• Day shift.