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Clinical Documentation Specialist (REMOTE) ~ Health Information Management ID- 10689

About the position

Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review. Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.

Responsibilities

  • Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation.
  • Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
  • Achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients.
  • Participates in the development and delivery of education for providers and members of the healthcare team.

Requirements

Nice-to-haves

  • Current Registered Nurse License.
  • Registered Health Information Administrator (RHIA).
  • Registered Health Information Technician (RHIT).
  • Certified Coding Specialist (CCS).
  • Certified Clinical Documentation Specialist (CCDS).
  • Certified Documentation Improvement Professional (CDIP).
  • Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder.
  • Experience with databases, spreadsheet software and presentation software.

Benefits

  • Diversity, equity, and inclusion initiatives.
  • Equal Opportunity Employer.
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