Remote Clinical Documentation Specialist (CDS)
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Job Description
About the Company
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Job Description
Remote Clinical Documentation Specialist (CDS)
Job Summary
The Remote Clinical Documentation Specialist (CDS) is responsible for improving the quality and completeness of clinical documentation in the patient medical record. The CDS works collaboratively with physicians, other healthcare professionals, and the coding team to ensure that clinical information is present and accurate. This information is used for coding, billing, quality reporting, and patient care planning.
Core Responsibilities
• Review clinical documentation during patient admissions, prospectively, or retrospectively to identify opportunities for improvement.
• Communicate identified opportunities to physicians and facilitate appropriate modifications to clinical documentation.
• Perform concurrent and prospective/retrospective medical record reviews to ensure the quality, completeness, and accuracy of documentation.
• Submit electronic queries to clinicians to ensure complete and accurate documentation for coding assignments.
• Reconcile records daily in CDI software to ensure appropriate reporting.
• Maintain required metrics and meet productivity standards.
• Participate in meetings, conference calls, and presentations.
• Adhere to departmental policies and procedures.
• Participate in assuring hospital compliance with regulatory requirements.
• Submit ideas to improve workflow and productivity.
Qualifications
• Bachelor’s degree in nursing or other health-related field (preferred)
• Certification as a Clinical Documentation Specialist, Coding Specialist, or Document Improvement Practitioner
• Registered Nurse (Single State) or RN – Multi-state Compact
• Minimum 5 years of healthcare experience (preferred)
• Strong medical surgical and/or critical care background (preferred)
• Minimum 2 years of clinical documentation improvement experience (preferred)
• Experience with care coordination/utilization management, coding/DRG, billing, auditing, and various healthcare payers (preferred)
• Clinician preferred and/or CDIP/CCDS credential (preferred)
• Licensed, knowledgeable, and uphold the practice of nursing as outlined by the American Nurses Association (required)
• EPIC Electronic Medical Record and CDI Software experience (preferred)
• Self-directed with good written communication skills
• Minimum MS Office (Word, Outlook, Excel, and PowerPoint) knowledge and expertise
• Chart review experience required
• Regulatory background and DRG reimbursement knowledge and strong understanding of coding methodologies and guidelines (preferred)
