Clinical Documentation Specialist

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

📋 Description

• Enhance the quality and thoroughness of clinical documentation to ensure that medical records accurately reflect patients' severity of illness, clinical requirements, and resource usage.

• Examine death medical records to guarantee that the severity of illness and mortality risk are recorded at the highest level.

• Assess all types of hospital admissions to confirm that severity is documented and provide education to providers regarding admission classifications.

• Analyze health record documentation to pinpoint significant diagnoses, treatments, and procedures that impact acuity and resource consumption.

• Utilize knowledge of disease processes, surgical procedures, UHDDS, CMS/NCHS ICD-10 coding guidelines, and coding classifications.

• Collaborate with physicians, nursing staff, caregivers, coding personnel, and other healthcare team members to clarify clinical documentation.

• Promote precise documentation, coding, and reimbursement practices, ensuring that documentation reflects the highest degree of specificity.

• Create and deliver training on clinical documentation improvement, coding standards, and regulatory compliance.

• Carry out additional responsibilities as assigned.

⛳️ Requirements

• Must be a Registered Nurse (RN) with a current license and possess 4 years of inpatient clinical experience in Emergency, Critical Care, or Medical/Surgical fields, including experience in Quality, Case Management, Clinical Audit, or Data Abstraction.

• Alternatively, coding professionals with CCS certification and 6 years of inpatient coding experience are also eligible.

• Coding professionals must have documented education in anatomy/physiology and pharmacology.

• CCDS certification is required within 6 months of hire.

• Current CCDS certification is preferred.

• A resume is required.

• A list of three professional references is required, including their name, email, and business title.

• Proof of legal work authorization in the United States must be provided on the first day of employment.

• Candidates are subject to pre-employment screenings, including criminal background checks, drug testing, and/or education verification.

• Capability to apply ICD-10 Official Coding Guidelines, UHDDS definitions, and knowledge of disease processes and surgical procedures.

• Proficiency in using the Vizient calculator.

• Ability to analyze health record documentation to identify diagnoses, treatments, and procedures affecting acuity and resource utilization.

🏝️ Benefits

• Medical, Dental, and Vision plans available for eligible staff and their families.

• Holiday, Vacation, and Sick Leave benefits.

• Educational discounts for staff and dependents (undergraduate only).

• Up to 10% matched contribution from UAMS.

• Basic Life Insurance coverage up to $50,000.

• Opportunities for Career Training and Education.

• Merchant Discounts available.

• Concierge prescription delivery on the main campus when utilizing UAMS pharmacy.