Clinical Documentation Specialist, Per Diem

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

📋 Description

• Conduct clinically-focused concurrent and retrospective reviews of inpatient medical records.

• Assess the utilization and documentation of acute care services.

• Assist in ensuring that physician documentation accurately reflects the patient's severity of illness and mortality risk.

• Perform reviews mandated by internal standards and external payers or regulatory bodies.

• Promote accurate and compliant reimbursement for acute care services.

• Contribute to the reporting of quality-of-care outcomes.

⛳️ Requirements

• A Bachelor’s degree in Nursing or Health Information Management is mandatory, or an equivalent combination of education and experience.

• RN or CCS certification is required.

• CCDS certification is preferred.

• At least 6 years of relevant experience, which includes either 6 years of clinical experience with 3 years in inpatient case management or 6 years in inpatient coding with DRG Validation.

• Previous experience in Clinical Documentation Specialist (CDS) roles is preferred.

• Familiarity with care delivery documentation systems and associated medical record documents.

• Understanding of age-specific needs, disease processes, and relevant procedures.

• Comprehensive clinical knowledge and understanding of pathology and physiology.

• Strong written and verbal communication skills.

• Excellent critical thinking abilities.

• Proficient knowledge of inpatient admission criteria.

• Capacity to work independently in a time-sensitive environment.

• Proficient computer skills and familiarity with basic office equipment.

• Ability to facilitate continuous communication with physicians.

• Capability to adapt to changes in workload and effectively prioritize tasks.

• Knowledge of the Medicare reimbursement system and coding structures is preferred but not essential.

🏝️ Benefits

• Comprehensive medical, dental, vision, and pharmacy benefits.

• Opportunities for contract increases.

• Flexible Spending Accounts available.

• 403(b) savings match program.

• Option for earned time cash-out.

• Paid time off provided.

• Career advancement opportunities offered.

• Resources available to support employee and family wellbeing.