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

📋 Description

• Assist in the evaluation and enhancement of inpatient medical records to ensure the quality, completeness, clinical severity, and accuracy of clinical documentation for DRG-based or APR-based payor populations.

• Review inpatient medical records within 24–48 hours of admission to verify accuracy, completeness, compliance, and identify documentation improvement opportunities.

• Work collaboratively with physicians and healthcare providers to foster improvements in documentation.

• Develop basic compliant verbal or written queries to resolve conflicting, ambiguous, or nonspecific documentation.

• Identify and assess clinical indicators that support accurate patient diagnoses.

• Implement current and emerging strategies to enhance patient-care documentation and record accuracy.

• Raise issues to Senior Clinical Documentation Specialists, providers, or administrators as needed.

• Partner with senior CDS staff on complex cases and educational requirements.

• Maintain a solid understanding of risk management and quality indicators, including PSIs, HACs, and PPCs.

⛳️ Requirements

• Minimum of two (2) years of nursing experience in Acute Care, Utilization Review, Case Management, and/or Quality Management.

• A valid RN license is required.

• Strong knowledge of evidence-based clinical guidelines.

• Proficient computer skills and familiarity with associated software applications.

• Exceptional verbal and written communication abilities.

• Outstanding analytical and problem-solving skills.

• Previous nursing experience in the Emergency Department (ER), Intensive Care Unit (ICU), Medical-Surgical (Med-Surg), Trauma, or Surgical Services is preferred.

• General knowledge of ICD-10 Inpatient Coding Guidelines is preferred.

• Solid understanding of resource and utilization management and regulatory guidelines is preferred.