Clinical Documentation Specialist

Medical writerMedical writerFull TimeRemoteMid LevelTeam 1-10Since 2001H1B No SponsorCompany SiteLinkedIn

Location

United States

Posted

171 days ago

Salary

Not specified

Seniority

Mid Level

2 yrs expEnglish

Job Description

• Review and evaluate medical record documentation for completeness, accuracy, and compliance • Collaborate with physicians, nurses, and coding professionals to ensure appropriate clinical documentation • Identify opportunities for documentation improvement to support coding accuracy, reimbursement, and clinical outcomes • Analyze medical records to ensure documentation supports quality care and appropriate reimbursement • Formulate compliant, clinically sound physician queries • Support accuracy of coded data and compliance with regulatory requirements to improve clinical outcomes reporting

Job Requirements

  • 2 years of clinical documentation improvement (CDI) experience
  • Registered Nurse (RN) certification
  • Knowledge of ICD-10-CM, MS-DRGs, coding guidelines, and compliance standards
  • Excellent communication, critical thinking, and organizational skills
  • Comfortable using MS Office, email, VPNs, virtual machines, two-factor authentication, and video conferencing tools (MS Teams, Zoom, etc.)
  • Experience using 3M and Epic preferred but not required

Benefits

  • full benefits package
  • PTO
  • top pay
  • Collaborative, mission-driven team environment
  • Opportunities for continuous learning, education and professional growth
  • Leadership that values your expertise and input

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