Fully Remote : Clinical Documentation Specialist

Job Description

Facilitate the improvement of clinical documentation by collaborating with physicians, nursing staff, and other patient caregivers. Perform concurrent and retrospective reviews of medical records to ensure accurate documentation of patient care. Educate healthcare providers on the importance of accurate and complete clinical documentation. Utilize clinical knowledge and expertise to identify opportunities for documentation improvement. Ensure compliance with regulatory requirements and guidelines. Participate in multidisciplinary team meetings to discuss documentation improvement strategies. Provide feedback to healthcare providers on documentation practices and areas for improvement. Maintain up-to-date knowledge of clinical documentation standards and best practices.

Responsibilities

• Facilitate the improvement of clinical documentation by collaborating with physicians, nursing staff, and other patient caregivers.
• Perform concurrent and retrospective reviews of medical records to ensure accurate documentation of patient care.
• Educate healthcare providers on the importance of accurate and complete clinical documentation.
• Utilize clinical knowledge and expertise to identify opportunities for documentation improvement.
• Ensure compliance with regulatory requirements and guidelines.
• Participate in multidisciplinary team meetings to discuss documentation improvement strategies.
• Provide feedback to healthcare providers on documentation practices and areas for improvement.
• Maintain up-to-date knowledge of clinical documentation standards and best practices.

Qualifications

• Registered Nurse (RN) with a current license from any state.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification.
• Certified Coding Specialist (CCS) certification if they have the CCDS 2 certification.
• Minimum of 3 years of clinical nursing experience.
• Strong knowledge of clinical documentation standards and regulatory requirements.
• Excellent communication and interpersonal skills.
• Ability to work collaboratively with healthcare providers and multidisciplinary teams.
• Proficiency in electronic health record (EHR) systems.

Additional Skills

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification.
• Certified Coding Specialist (CCS) certification if they have the CCDS 2 certification.

Work Environment

Fully remote role. Schedule: Monday-Friday 9am-5pm with potential for flexibility as long as 40-hour weeks are maintained.