Clinical Documentation Specialist - Coding

Clinical Documentation Specialist - Coding

Immediate need for a talented Clinical Documentation Specialist - Coding. This is a 06+months contract opportunity with long-term potential and is located in California (Remote). Please review the job description below and contact me ASAP if you are interested.

Key Responsibilities:

• Conduct concurrent medical record reviews within an electronic health record (EHR) environment to ensure accurate and complete documentation.
• Collaborate with physicians and medical coding staff to identify and clarify additional diagnoses impacting severity of illness and risk of mortality indicators.
• Prioritize and manage multiple cases daily to ensure timely and accurate documentation improvements.
• Provide coverage for multiple Northern California facilities as needed based on census and staffing demands.
• Facilitate accurate clinical documentation to reflect the level of service provided to patients.
• Analyze medical records for clinical indicators, symptoms, and diagnoses to identify opportunities for documentation improvement.
• Develop and issue physician documentation clarification queries per coding guidelines and compliance standards.
• Monitor, track, and report the impact of documentation improvement efforts, including query response rates and documentation trends.
• Provide education and feedback to physicians regarding best practices for clinical documentation.
• Conduct data analysis and root cause assessments to support ongoing improvement efforts.
• Collaborate with regional CDI leadership, medical staff, and coding professionals to align documentation practices with clinical and regulatory standards.
• Support policy and procedure development for documentation integrity.
• Participate in special projects, committees, and training programs related to CDI program enhancements.

Key Requirements and Technology Experience:

• Minimum of four (4) years of clinical nursing experience in inpatient care, clinical documentation, discharge planning, or case management.
• Bachelor's degree OR four (4) years of directly related experience in clinical documentation, inpatient care, or case management.
• Strong ability to interpret physician documentation and clinical indicators for documentation enhancement.
• Demonstrated autonomy in decision-making and workflow management.
• Excellent interpersonal and communication skills (verbal and written).
• Ability to conduct and interpret quantitative/qualitative data analysis.
• Leadership skills in project management and consulting.
• Knowledge of adult learning theory and its application in training and orientation.
• Strong time management and organizational skills.
• Ability to work effectively in a Labor/Management Partnership environment.
• Experience working with electronic health records (Epic).
• Experience using 3M Encoder.
• Familiarity with Hierarchical Condition Categories (HCCs).
• Clinical experience in Intensive Care Unit (ICU) settings preferred.
• Minimum of two (2) years of Clinical Documentation Integrity/Improvement experience.
• Minimum of three (3) years of inpatient clinical patient care experience.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Experience in chart review, auditing, utilization management, case management, or discharge planning preferred.
• Knowledge of ICD-CM classification, MS-DRGs, and payment methodologies preferred.
• Advanced degrees such as BSN, MSN, MS (with NP/PA licensure), MBS, or MD preferred.
• Compensation for this role is subject to periodic review and adjustments.
• The employer reserves the right to modify job descriptions, compensation structures, and employment classifications as needed.
• Employees will be notified of any changes impacting their roles.