Registered Nurse Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Integrity Specialist - Second Level Reviewer.

Key Responsibilities

• Conducts comprehensive clinical chart reviews to ensure accurate documentation reflecting patient care and diagnosis
• Collaborates with various healthcare professionals to address documentation discrepancies and improve quality
• Tracks and documents secondary review results, providing education and feedback to stakeholders

Required Qualifications

• Graduation from an accredited School of Nursing (BSN, ADN) or medical school (MD or equivalent) or a Bachelor's/Master's Degree in a health-related field
• Current licensure as a Registered Nurse, MD, or equivalent, or credentialed as a Medical Coder through AHIMA
• 4-6 years of relevant experience in clinical documentation, CDI second level review, or inpatient coding quality review
• Strong understanding of disease processes, clinical indications, and documentation requirements for accurate coding
• Must maintain credentials while employed