RN Clinical Documentation Specialist (Remote)

We are looking for Clinical Documentation Specialists to support one of our top clients on a Contract to Hire basis. This role will be 100% remote. Must have a compact RN License!

Location: Fully Remote, must be located in a compact license state

Pay: $32-52/hr depending on experience

Role Overview:

We are looking for a skilled and dedicated Clinical Documentation Specialist (CDS) who holds a valid Registered Nurse (RN) license and is certified in either CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner). In this role, the CDS will be essential in ensuring that clinical documentation is accurate, complete, and compliant, reflecting the quality of care provided and supporting proper coding and reimbursement practices. This position requires close collaboration with physicians, clinical teams, and coding professionals to enhance clinical documentation and support patient care.

• Review and assess patient clinical documentation for accuracy, completeness, and adherence to established standards.
• Work closely with healthcare providers to resolve unclear or incomplete documentation.
• Educate physicians and clinical staff on best practices for documentation, emphasizing the role of accurate documentation in coding and reimbursement.
• Perform both concurrent and retrospective medical record reviews to identify opportunities for improving documentation.
• Ensure compliance with regulatory guidelines and organizational policies related to clinical documentation and coding.
• Track and report clinical documentation performance metrics to clinical leadership.
• Stay up-to-date with the latest standards, coding updates, and regulations through participation in training programs.
• Utilize data analysis tools to identify trends in documentation and collaborate with interdisciplinary teams on process improvements.
• Assist in preparing documentation for external audits and support third-party payer or regulatory reviews.
• Contribute to quality improvement efforts by ensuring documentation accurately reflects patient severity of illness and risk of mortality.

Qualifications:

• Valid and active Registered Nurse (RN) license (Must be compact)
• 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.

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