Clinical Documentation Specialist II - RN - Remote

Overview

The Clinical Documentation Specialist II plays a crucial role in improving the accuracy and quality of patient documentation, ensuring compliance and optimal reimbursement.

In Short

• Assists in identifying diagnoses and procedures during patient hospitalization.
• Initiates queries to providers based on medical record documentation.
• Collaborates with coding, clinicians, and medical staff.
• Reviews inpatient records for completeness and accuracy.
• Identifies opportunities for documentation improvement.
• Interacts directly with physicians for additional documentation.
• Maintains relationships with Health Information Coding staff.
• Participates in developing physician education materials.
• Adheres to ethical and professional business practices.
• All other duties as assigned.

Requirements

• Bachelor’s in Nursing required.
• RN License required.
• Clinical Documentation Specialist Certification via ACDIS or AHIMA.
• 2-5 years of medical/surgical nursing experience.
• Minimum of 2 years recent experience in CDI role.
• Critical Care and/or Emergency Nursing experience required.
• Proficient in query writing.
• Organizational and critical thinking skills required.
• Experience with computer systems and Microsoft Office applications.
• Ability to complete chart audits accurately.

Benefits

• Comprehensive compensation and benefits.
• Opportunities for continuous learning and growth.
• Support for achieving a healthy work-life balance.
• Collaborative and innovative work culture.
• Equal Opportunity Employer/Veterans/Disabled.