Clinical Documentation Specialist

Working remotely on a per diem basis, the Clinical Documentation Specialist will review medical records for accuracy and completeness, facilitate documentation improvement by communicating with healthcare professionals, and ensure compliance with regulatory requirements. Key responsibilities: Review medical records concurrently to ensure compliance with documentation standards and regulatory requirements Prepare and communicate well-written queries to physicians regarding missing or incomplete information in medical records Educate and interact with healthcare providers to promote correct coding and documentation practices Required qualifications: Bachelor of Science in Nursing, Health Information Management, or related field CCDS or CDIP certification preferred; RN/BSN preferred 5 years of experience in Critical Care/Emergency medicine or Medical Surgical experience preferred 2-3 years of Clinical Documentation Improvement experience or 5 years of Coding experience preferred Familiarity with Medicare reimbursement systems and coding structures preferred