RN Clinical Documentation Specialist

This is a fully remote position, open to applicants in Alabama, +31 more states.

📋 Description

• Enhance the overall quality and completeness of provider-based clinical documentation within medical records.

• Assist healthcare providers in ensuring that documentation accurately represents DRG, severity of illness, risk of mortality, risk adjustment, and the complexity of patient care.

• Review medical records and address any documentation ambiguities.

• Offer expert knowledge on DRG and clinical documentation opportunities and requirements.

• Act as a liaison between acute care coding and providers to accurately capture DRG, reimbursement, and patient care complexity.

• Perform precise and timely concurrent record reviews utilizing specialized training and software.

• Develop clinically credible and compliant queries for provider documentation clarification.

• Maintain accurate and complete entries in the clinical documentation database and ensure case reconciliation.

• Verify the accuracy of clinical information used for reporting outcomes for providers and facilities.

• Provide education to clinicians and facility management through presentations and reports.

• Operate independently in a remote model while managing responsibilities across multiple facilities/entities.

• Engage extensively with providers, Health Information Management Services (HIMS) professionals, nursing, and ancillary staff.

⛳️ Requirements

• A Registered Nurse (RN) license in the state of residence.

• Comprehensive knowledge of clinical care typically acquired through a bachelor's degree in nursing.

• A minimum of two years of acute clinical care experience.

• Proficiency in interfacing with various software applications.

• Ability to work autonomously.

• Proven critical thinking and problem-solving skills.

• Strong communication and time management abilities.

• Capability to work effectively within an interdisciplinary team framework.

• Must reside in one of the following states: Alaska, Alabama, Arkansas, Arizona, California, Colorado, Florida, Georgia, Iowa, Idaho, Indiana, Kansas, Kentucky, Michigan, Minnesota, Missouri, Mississippi, North Carolina, North Dakota, Nebraska, New Mexico, Nevada, New York, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin, or Wyoming.

• Availability to work at least 75% of shifts between 7 AM to 7 PM AZT/MST.

• Candidates should be self-motivated and possess moderate to strong technical skills.

• Must be able to meet daily and weekly productivity targets.

🏝️ Benefits

• Options for health and financial security.

• Fully remote work arrangement.

• Monday to Friday, 8-hour shifts.

• No weekend or holiday work required.