Working primarily in a remote environment, the full-time Clinical Documentation Improvement Specialist will review medical records to ensure accurate documentation of clinical treatments and diagnoses, while collaborating with healthcare professionals to enhance documentation quality and compliance. Key responsibilities Review medical records for completeness and compliance with regulatory requirements, ensuring accurate documentation of diagnoses and procedures Prepare and communicate compliant queries to physicians regarding missing or clarifying information in medical records Educate healthcare providers on documentation standards and coding compliance while maintaining productivity expectations Required qualifications Bachelor of Science in Nursing, Health Information Management, or a related field CCDS or CDIP certification preferred; RN/BSN or RHIA/RHIT with CCS also considered 5 years of experience in Critical Care/Emergency medicine or Medical Surgical settings preferred 2-3 years of Clinical Documentation Improvement experience or 5 years of coding experience preferred Working knowledge of the Medicare reimbursement system and coding structures preferred
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