Clinical Documentation Specialist

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

📋 Description

• Conduct daily evaluations of Medical Staff and healthcare team documentation as part of the Clinical Documentation Program.

• Guarantee the quality and completeness of clinical documentation for Medicare, Medicaid, and other payers concerning the inpatient population.

• Examine patients’ clinical status, treatment plans, and medical histories to pinpoint documentation deficiencies.

• Collaborate with Coding staff to ensure that discharge diagnoses and comorbidities accurately represent patients’ clinical status and care.

• Ensure the timely, accurate, and complete clinical information necessary for measuring and reporting physician and hospital outcomes.

• Perform targeted second-level reviews of high- or low-outlier medical/surgical DRGs identified in quarterly PEPPER reports.

• Support education initiatives for Medical Staff, Residents, designated Committees, and hospital staff regarding the acquisition of appropriate medical-record documentation.

• Actively contribute to the departmental SMART goals that align with organizational strategic objectives.

• Utilize monitoring tools to track the progress of the Clinical Documentation Program.

• Engage in the implementation of new service lines and identify documentation requirements for new diagnoses and procedures.

• Provide education to physicians and staff related to clinical documentation.

⛳️ Requirements

• A Bachelor's Degree is required.

• A Bachelor's Degree in nursing or a clinical degree in a related field is preferred.

• Minimum of two (2) years’ experience in the clinical field, coding, care management, or a comparable combination of education, training, and/or experience that demonstrates competence.

• Strong clinical background is essential.

• Exceptional problem-solving, time-management, and organizational abilities are required.

• Capacity to work independently and communicate effectively and efficiently with Medical Staff and the Healthcare Team.

• Strong familiarity with medical practices, particularly in disease management and health and wellness programs.

• Extensive knowledge of medical terminology and regulatory agency requirements is necessary.

• Exceptional written and verbal communication skills are required.

• Tact, initiative, and confidence to execute the essential functions of the position are essential.

• One of the following credentials is required: Registered Nurse - South Carolina Department of Labor, Licensing and Regulation; Registered Health Information Administrator - American Health Information Management Association; or Certified Coding Specialist - American Health Information Management Association.

• Light physical demand is expected.

🏝️ Benefits

• Day - 8 hour shift.

• Year-round access to the warm, sunny climate and outstanding quality of life in the Myrtle Beach area.

• Workplace culture centered on inclusion, teamwork, mutual respect, and recognition.

• Equal Opportunity Employer.