Clinical Documentation Specialist (CDS)

Seeking an experienced Clinical Documentation Specialist (CDS) for a full-time remote position, responsible for enhancing documentation integrity in inpatient care through record review, education, and consultation while ensuring compliance with documentation standards. Key responsibilities Conduct extensive reviews of patient health records to ensure clarity, completeness, and accuracy of clinical documentation Communicate and educate healthcare providers on documentation requirements and monitor engagement for improvement Collaborate with coding staff to ensure comprehensive documentation of diagnoses and resolve discrepancies in a professional manner Required qualifications Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or an advanced degree in a medical field Current Registered Nurse License, RHIA, RHIT, CCS, or licensure as a PA/NP/APN Preferred Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) Two years of experience in Critical Care, Medical or Surgical Inpatient Care Nursing, or as an inpatient coder