Clinical Documentation Specialist - 100% Remote (Must Live in FL, TN, GA, LA, WA State, or TX)
About the position
Responsibilities
• Improve the quality, completeness, and accuracy of clinical documentation through open record reviews.
• Support the accuracy of clinical information for measuring and reporting outcomes.
• Seek additional information regarding clinical conditions from clinical personnel and track responses.
• Conduct follow-up reviews of clinical documentation to ensure clarifications are recorded.
• Demonstrate knowledge of DRG payor issues and clinical documentation requirements.
• Request clarifications from physicians for unclear diagnoses and procedures.
• Identify appropriate ICD10 codes for diagnoses or procedures as needed.
• Educate internal customers on clinical documentation opportunities and reimbursement issues.
Requirements
• Associate's or bachelor's degree in nursing or a medical school graduate where Western Medicine is practiced.
• For RN: At least five years of recent clinical experience in an acute care hospital setting; coding and utilization review experience preferred.
• For Medical School graduate: One year of clinical experience preferred.
• Registered Nurse licensure in Texas or Compact State within 60 days, or Temporary State Licensure within 60 days.
• CCDS, CDIP, or CCS certification for Medical School graduates.
Nice-to-haves
• Experience in coding and utilization review.
• Strong analytical thinking and problem-solving skills.
Benefits
• Comprehensive health insurance coverage.
• Retirement savings plan options.
• Paid time off and holidays.
• Professional development opportunities.
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