Clinical Documentation Specialist
J
JobgetherHealthcare
Fully remote position within the United States, subject to state eligibility requirements.Part-TimeMiddle
Salary41,600 - 134,680 USD per year
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Job Details
- Experience
- 1–2 years
Requirements
- Associate degree in Health Information Management or a related field.
- 1–2 years of inpatient coding experience.
- Active Registered Nurse (RN) license or a relevant certification such as RHIA, RHIT, CCS, CDIP, or CCDS.
- Experience with acute-care inpatient coding or clinical documentation improvement is preferred.
- Bachelor’s degree in Nursing, Health Information Management, or a related field is preferred.
- Strong understanding of clinical documentation, inpatient coding principles, and health information management practices.
- Excellent analytical and critical-thinking skills.
- Strong written and verbal communication skills.
- High attention to detail, accuracy, and organization.
- Ability to work effectively and independently in a remote setting.
Responsibilities
- Review patient medical records to improve the overall quality, accuracy, and completeness of clinical documentation.
- Assess documentation to ensure it appropriately reflects the patient’s severity of illness and the level of services rendered.
- Collaborate with providers, coders, and other patient care team members to support comprehensive and accurate patient documentation.
- Identify documentation opportunities and assist providers in clarifying clinical information when appropriate and compliant.
- Formulate, monitor, and respond to documentation clarification requests in accordance with applicable requirements and best practices.
- Develop and deliver clinical documentation improvement education and guidance to providers.
- Promote consistent documentation practices that support accurate clinical representation and effective health information management.
- Work independently in a remote environment while maintaining accuracy, responsiveness, and adherence to established processes.
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