Job Description
We are seeking a skilled and dedicated Clinical Documentation Specialist (CDS) to join a dynamic healthcare team in a fully remote role. This position offers an exciting opportunity for individuals with a passion for ensuring accurate, complete, and compliant clinical documentation, which plays a vital role in patient care, coding, and reimbursement. If you're looking for a rewarding career where your expertise truly makes a difference, we'd love to hear from you!
Location: Fully Remote (must be located in a compact license state)
Pay: $32-$52 per hour, depending on experience
Role Overview:
As a Clinical Documentation Specialist, you will be responsible for reviewing and enhancing patient documentation, ensuring it accurately reflects the care provided. You'll work closely with healthcare providers, physicians, and clinical teams to improve the quality of documentation and support effective coding and reimbursement. This role is integral to maintaining high standards of care and compliance within the healthcare system.
Key Responsibilities:
Review and assess clinical documentation for accuracy, completeness, and adherence to standards and regulations.
Collaborate with physicians and clinical teams to resolve any unclear or incomplete documentation.
Educate healthcare providers on best practices for documentation, emphasizing its importance in coding and reimbursement.
Conduct both concurrent and retrospective medical record reviews to identify opportunities for documentation improvement.
Ensure compliance with regulatory guidelines and organizational policies related to clinical documentation.
Track and report performance metrics related to clinical documentation to leadership teams.
Stay current with coding updates, regulations, and industry standards by participating in ongoing training.
Utilize data analysis tools to identify trends and collaborate with interdisciplinary teams to implement process improvements.
Assist in preparing documentation for external audits and support third-party payer or regulatory reviews.
Contribute to quality improvement efforts by ensuring that documentation accurately reflects patient severity of illness and risk of mortality.
Qualifications:
Valid and active Registered Nurse (RN) license (must be compact)
CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) certification required
2-3 years of experience in clinical documentation improvement, coding, or related healthcare roles
Strong knowledge of ICD-10 coding, DRGs, and reimbursement methodologies
Excellent communication and interpersonal skills for collaboration with physicians, nursing staff, and coders
Ability to work independently and handle multiple priorities in a fast-paced healthcare environment
Proficiency with clinical documentation software and electronic health record (EHR) systems
If you meet the qualifications and are ready to make a meaningful impact in a remote setting, we encourage you to apply today!
Employment Type: Full-Time
Salary: $ 32.00 52.00 Per Hour
Job Tags
Hourly pay, Full time,