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Role Description

The Clinical Documentation Specialist enhances the overall quality and accuracy of clinical documentation on a concurrent and retrospective basis through daily review and interactions with physicians and healthcare providers. They utilize clinical and coding expertise to analyze documentation, ensuring it accurately reflects the level of service provided. This role supports timely and precise capture of quality metrics to improve patient care, physician documentation, and hospital outcomes.

• Perform daily review of clinical documentation and interact with physicians and providers to ensure completeness and accuracy.
• Analyze and evaluate documentation to ensure it reflects appropriate levels of care and supports quality measures.
• Support timely coding and documentation processes to optimize hospital and physician performance metrics.
• Collaborate with clinical teams to identify documentation gaps and implement improvement strategies.
• Stay current with coding guidelines, documentation standards, and quality measurement requirements.
• Maintain compliance with regulatory and accreditation standards related to clinical documentation.
• Support education and training initiatives for staff regarding documentation best practices.
• Utilize clinical and coding expertise to support continuous quality improvement initiatives.

Qualifications

• Associate’s Degree required; Bachelor's Degree preferred.
• 0-3 years of relevant experience in clinical documentation, coding, or related fields.
• Active Registered Nurse (RN) license in Indiana or Nurse Licensure Compact (NLC) RN license, or RHIA/RHIT and/or CCS certification.
• If RN licensed, 3-5 years of strong, varied clinical experience in an acute care setting preferred.
• CCDS and/or CDIP credential preferred; obtain within 4 years of hire.
• Ability to work independently and produce high-quality outcomes.
• Working knowledge of computers and software applications such as Microsoft Office Suite (Outlook, Word, Excel, PowerPoint, SharePoint, Teams) and Cerner EMR.
• Ability to sit for extended periods.
• Position is remote but may require occasional on-site meetings with advanced notice.

Benefits

• Comprehensive benefits package including health, dental, and vision insurance
• Retirement savings plan with employer match
• Tuition reimbursement and professional development opportunities
• Employee assistance programs and wellness initiatives
• Supportive work environment committed to safety and excellence