Clinical Documentation Specialist I
J
JobgetherHealthcare
Fully remote working arrangement within the United States.Full-TimeSenior
Salary66,830.4 - 124,300.8 USD per year
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Job Details
- Experience
- At least 5 years of acute care nursing or clinical experience
- Required Skills
- EHR
Requirements
- Have at least 5 years of acute care nursing or clinical experience, including experience in medical-surgical units, intensive care, post-acute care, or emergency departments.
- Hold an active and applicable professional clinical credential; accepted qualifications include RN, PA, MD, CRNP, ACNPC, or ECFMG.
- A Bachelor's or Master's degree in Nursing is preferred.
- Relevant educational backgrounds may include Health Services Administration, Business Administration, Systems Performance Engineering, Industrial Engineering, or Public Health.
- Previous experience as a Clinical Documentation Specialist is preferred.
- CCDS or CDIP certification is an advantage.
- Demonstrate strong knowledge of pathophysiology, disease processes, medical treatments, and clinical terminology.
- Understand clinical documentation requirements and the appropriate identification and representation of patient conditions and medical procedures.
- Familiarity with medical coding principles and healthcare quality guidelines is preferred.
- Have strong interpersonal, written, and verbal communication skills for working with physicians and multidisciplinary healthcare teams.
- Demonstrate analytical, critical-thinking, problem-solving, and deductive-reasoning abilities when reviewing complex clinical information.
- Be able to organize and prioritize concurrent cases, follow-up activities, and competing deadlines, and maintain accurate electronic records using multiple software applications.
Responsibilities
- Educate physicians, nursing staff, allied health practitioners, and other patient-care team members on clinical documentation regulations, standards, and best practices.
- Communicate with physicians and healthcare providers to promote accurate, complete, and clinically appropriate medical documentation.
- Conduct concurrent medical record reviews for completeness, accuracy, and compliance with clinical and quality guidelines.
- Identify documentation gaps and inconsistencies related to severity of illness, risk of mortality, and quality indicators.
- Develop clinically supported clarification requests for inpatient cases and prepare CDI severity worksheets.
- Follow up on active cases, prioritize records requiring clarification, and monitor physician responses.
- Collaborate with clinical staff to resolve documentation discrepancies, coding questions, and record inconsistencies.
- Enter and maintain accurate information in CDI software systems and transcribe clarifications when appropriate.
- Participate in departmental meetings, communicate outstanding issues, and identify opportunities for clinical documentation education.
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