A leading healthcare organization is currently seeking a fully remote Clinical Documentation Specialist to join their team. This vital role supports accurate reimbursement and high-quality data reporting in inpatient settings.
About the Opportunity:
- Schedule: Monday to Friday
- Hours: 8am to 5pm or 9am to 6pm (flexible hours available)
- Setting: Remote, open to candidates living anywhere in the EST time zone
Responsibilities:
- Lead efforts to facilitate improvement in the overall quality and completeness of provider-based clinical documentation in the medical record by working directly with providers
- Support providers by ensuring that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchical condition categories of the patient
- Identify and act on opportunities for documentation improvement and hold collaborative discussions with providers
- Serve as a subject matter expert and assist less experienced team members in understanding and following operational policies
- Train and onboard new team members and participate in special projects assigned by the Mid Revenue Cycle leadership
- Conduct thorough assessments of clinical documentation through extensive medical record review and utilization of clinical judgment, deployment of artificial intelligence
- Collaborate directly with providers to clarify the documentation to accurately and completely reflect the patients’ medical conditions
- Perform other duties, as needed
Qualifications:
- 6+ years of Acute Care Clinical Documentation experience
- Associate’s Degree in Nursing, HIM, or another Healthcare related field
- Proven record of combining Clinical knowledge and Coding skills
- Knowledge of Healthcare Regulatory environment
- Microsoft Office proficiency
- Solid analytical and problem-solving skills
- Great interpersonal skills
- Excellent communication skills (written and verbal)
- Strong attention to detail
- Highly organized
Desired Skills:
- 4+ years of experience in Oncology
- Any (one) of the following certifications:
- (CCDS) Certified Clinical Documentation Specialists from ACDIS
- (CDIP) Certified Documentation Integrity Practitioner from AHIMA
- (CDEI) Certified Documentation Expert Inpatient from AAPC
-
Registered Nurse (RN) *in lieu of a certification listed above, an (active)
