Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist I to support value-based care and ensure accurate clinical documentation.

Key Responsibilities

• Determine principal and secondary diagnoses and assign appropriate working DRGs based on medical record reviews
• Educate providers on documentation practices to enhance diagnostic specificity and reflect patient conditions accurately
• Maintain records of review and query activities, meet performance targets, and participate in departmental improvement initiatives

Required Qualifications

• High School Diploma/GED or equivalent
• Five years of experience as a clinical nurse in a high acuity department or as an inpatient/outpatient coder, or two years as a Clinical Documentation Integrity Specialist
• Associate's Degree in a healthcare-related field (preferred)
• Registered Nurse (RN) in the current state of employment (preferred)
• Experience with ICD10-CM, CPT, HCC, and HCPCS coding (preferred)