Job Title: Clinical Documentation Specialist (RN)

Location: 100% Remote

Job Type: Full-Time, Contract to Hire

Pay: $32/hr - $52/hr

Duration: Contract to Hire

Position Summary:

We are seeking a dedicated and experienced Clinical Documentation Specialist (CDS) with a valid Registered Nurse (RN) license and certification in CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner). The CDS will play a critical role in ensuring the accuracy, completeness, and compliance of clinical documentation to reflect the quality of care provided and to support appropriate coding and reimbursement practices. This role involves close collaboration with physicians, clinical staff, and coding professionals to optimize clinical documentation and support patient care.

Key Responsibilities:

• Review and analyze clinical documentation in patient records to ensure accuracy, completeness, and compliance with established standards.
• Collaborate with healthcare providers to clarify ambiguous or incomplete documentation.
• Educate physicians and other clinical staff on documentation best practices and the importance of clinical accuracy for proper coding and reimbursement.
• Conduct concurrent and retrospective reviews of medical records for documentation improvement opportunities.
• Ensure compliance with governmental regulations and internal policies regarding documentation and coding practices.
• Monitor clinical documentation performance metrics and report findings to clinical leadership.
• Participate in training programs to stay current with the latest clinical documentation standards, coding updates, and regulatory requirements.
• Utilize data analysis tools to track documentation trends and work with multidisciplinary teams to implement process improvements.
• Assist with external audits and prepare documentation as needed for review by third-party payers or regulatory agencies.
• Support quality improvement initiatives by ensuring documentation accurately reflects the severity of illness and risk of mortality.

Qualifications:

• Valid and active Registered Nurse (RN) license.
• CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) certification required.
• Minimum of 2-3 years of experience in clinical documentation improvement, coding, or related healthcare roles.
• Strong understanding of ICD-10 coding, DRGs, and reimbursement methodologies.
• Excellent communication and interpersonal skills to collaborate with physicians, nursing staff, and coders.
• Ability to work independently and manage multiple priorities in a fast-paced healthcare environment.
• Proficiency in clinical documentation software and electronic health record (EHR) systems.
• Strong analytical and problem-solving skills with attention to detail.

Preferred Qualifications:

• Experience with clinical documentation in a hospital or acute care setting.
• Knowledge of quality and regulatory reporting requirements, including Medicare and Medicaid guidelines.
• Familiarity with coding audits and denial management processes.

Medix is acting as an Employment Agency in relation to this vacancy.