Clinical Documentation Specialist - Remote

Overview

The Clinical Documentation Specialist is responsible for conducting reviews of patient medical records to ensure accuracy and completeness, while also interacting with healthcare professionals to improve documentation practices.

In Short

• Conducts concurrent and retrospective reviews of medical records.
• Ensures clinical documentation reflects the severity of illness.
• Collaborates with physicians and patient care teams.
• Identifies opportunities for documentation improvements.
• Maintains knowledge of coding and reimbursement guidelines.
• Utilizes critical thinking to analyze medical records.
• Communicates effectively with various stakeholders.
• Manages multiple activities and projects efficiently.
• Promotes an inclusive work environment.
• Maintains confidentiality of sensitive information.

Requirements

• Graduate of accredited nursing school or foreign trained physician.
• Registered Nurse license in California or equivalent.
• 5 years of relevant clinical experience.
• Strong clinical knowledge of diagnoses and disease processes.
• Ability to analyze and interpret clinical documentation.
• Excellent communication skills, both verbal and written.
• Proactive in problem-solving and workflow improvement.
• Ability to work in a fast-paced environment.
• Familiarity with essential applications and databases.
• Respect for cultural and linguistic diversity.

Benefits

• Comprehensive benefits package.
• Support for unique talents and strengths.
• Empowerment to innovate in patient care.
• Equal opportunity employer.
• Regular employee status with full-time hours.