Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist.

Key Responsibilities

• Perform initial and follow-up reviews of inpatient records to identify documentation improvement opportunities
• Utilize CDI software for accurate DRG, SOI, ROM, and POA assignments
• Develop and conduct educational programs for staff on documentation best practices

Required Qualifications

• An Associate's degree in health information technology or equivalent certification (RHIT, RHIA, RN) or a Bachelor's degree in a relevant field
• Three years of experience in an inpatient setting, in coding or clinical roles
• Adherence to the remote work agreement