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Clinical Documentation Specialist (Remote)
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Job Description
- Req#: 22021371
Employer Industry: Healthcare Services
Why consider this job opportunity:
- Salary up to $74.57/hour
- Opportunity for career advancement and growth within the organization
- Supportive and collaborative work environment
- Chance to make a positive impact on clinical documentation accuracy and patient care
- Regular interaction with healthcare professionals and opportunities for ongoing education
What to Expect (Job Responsibilities):
- Facilitate clarification of clinical documentation to ensure accuracy and integrity in the medical record
- Work with physicians to clarify documentation during concurrent reviews throughout the patient's inpatient stay
- Request and follow up on clarification of clinical documentation from physicians as needed
- Educate medical staff on clinical documentation opportunities that impact the accuracy of the medical record
- Input outcome data into CDI software for tracking and trending audit results
What is Required (Qualifications):
- Graduate from an accredited School of Nursing required
- Must obtain a Bachelor of Science in Nursing degree within 5 years of employment
- Current License to practice as a Registered Professional Nurse in New York State required
- Specialized certifications as needed (CCEDS, CDIP, CCDS, or CCS)
- 1-3 years of relevant experience required
How to Stand Out (Preferred Qualifications):
- Experience in clinical documentation improvement (CDI)
- Familiarity with ICD-10 CM and ICD-10 PCS coding
- Knowledge of MS-DRG and APR grouper logic
- Strong communication skills for interacting with medical staff
- Ability to exercise independent judgment on significant matters
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