Remote Clinical Documentation Specialist

@ Talentify.io

About the Remote Clinical Documentation Specialist Role

This position offers an opportunity to work remotely from select states across the U.S. in a supportive and collaborative environment. You will play a key role in improving clinical documentation practices to enhance patient care.

Key Responsibilities

• Conduct initial concurrent review and ongoing re-reviews of clinical documentation for selected admissions.
• Assign and update working DRG for encounters ensuring timely documentation.
• Identify documentation clarifications and initiate communication with physicians.
• Utilize monitoring tools to track progress of concurrent review programs.
• Provide information and education to physicians and ancillary staff.

Qualifications

Minimum qualifications include an Associate's Degree in Nursing (Bachelor's preferred) and active RN licensure. Candidates must have 3 years of clinical experience in an ICU/Critical Care acute care setting and 2 years as a clinical documentation specialist. Certification in CCDS or CDIP is required within two years of hire.

Preferred Qualifications

Experience in clinical documentation improvement initiatives, familiarity with coding guidelines and regulations, strong analytical skills, excellent communication abilities, and proficiency in CDI software will help you stand out.

Key skills/competency

• Clinical Documentation
• Concurrent Review
• DRG Assignment
• ICU/Critical Care
• RN Licensure
• CDDS/CDIP Certification
• Analytical Skills
• Communication
• Education
• CDI Software