Clinical Documentation Specialist

About This Role

This role involves reviewing medical records to find opportunities for clarifying diagnoses and clinical conditions. The specialist works with providers, coders, and other healthcare team members to ensure accurate documentation that supports compliant reimbursement, quality reporting, regulatory requirements, and organizational performance.

Responsibilities

• Review medical records to identify opportunities to clarify diagnoses and clinical conditions
• Collaborate with providers, coders, and other healthcare team members to ensure accurate documentation

Requirements

• Bachelor’s Degree in a related field preferred
• 5 years of recent experience in a clinical healthcare setting
• Prior experience in clinical documentation review preferred
• Understanding of ICD 10 coding requirements
• High level of clinical knowledge regarding the patient population served
• Ability to participate collaboratively with all members of the care team
• Ability to work with minimal supervision
• Ability to communicate verbally and in writing to individuals of varying education levels
• Current CA RN License, Nurse Practitioner, Physician Assistant, MD graduate/educated in UR or foreign country, Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)

Nice to have:

• CDS certification is encouraged but not required
• CCS is preferred but not required

Important Details

• Schedule: hybrid

About the Company

Salary offers are determined by the candidate’s relevant experience and skills. For per diem positions, a standard rate is used based on market data and not the candidate’s individual experience.