Clinical Documentation Specialist

To enhance the quality of medical records, the full-time North Carolina Licensed Clinical Documentation Specialist will facilitate modifications through collaboration with healthcare teams, conduct chart reviews, and provide ongoing education on documentation standards in a remote setting. Key responsibilities Review and modify clinical documentation to ensure accuracy regarding admission reasons, service intensity, and patient conditions Conduct timely chart reviews and communicate deficiencies to healthcare providers, ensuring compliance with documentation standards Provide education and resources to medical staff on documentation improvement techniques and maintain a database for statistical reporting Required qualifications BSN, PA, NP, or Doctorate degree in a medically related field Three years of progressive healthcare experience in an acute care setting Prior experience in chart review, case management, or utilization review is preferred Currently licensed as a professional nurse, physician assistant, or MD in North Carolina CCDS, CCS, or CDIP certification is preferred