Pennsylvania Licensed Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Specialist I.

Key Responsibilities

• Review and evaluate clinical documentation to ensure compliance with policies and procedures
• Apply clinical knowledge to assess medical records, including documentation and treatment plans
• Communicate with providers to clarify documentation and identify educational opportunities

Required Qualifications

• Bachelor's Degree in BSN, RHIA, or Master's Degree in CRNP, PA-C; or Associate's Degree in RN, RHIT; or Specialized Diploma in RN, CCS, CPC
• 5 years of advanced coding or clinical experience in an acute care hospital setting, or 1 year of CDI or coding experience
• Experience with medical record reviews and DRG validation
• Proficiency in MS Outlook, Word, Excel, and PowerPoint
• Relevant certifications (e.g., RHIT, RN, RHIA, CPC, CCS) required upon hire