Clinical Documentation Specialist

Clinical Documentation Specialist

Remote Job | 03/05/26

Job Description

Job Title: Clinical Documentation Specialist

Location: Remote, USA

Job Description:

Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.

Facilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients.

Educates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis

Applies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities.

Acute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses - obtaining missing information via a query when necessary.

Qualifications:

Must have at least one of the following:

License to practice as a Registered Nurse preferred (any state)

Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)

Must have all of the following:

1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience

CCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required

Additional Notes:

Candidate must have at least 1 year of experience with concurrent inpatient facility coding/clinical documentation improvement experience.

We are looking for someone who has had experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation obtaining missing information via a query when necessary, so accounts can be coded and billed appropriately for the services provided.

Regards,

Ajay Tanwar

E-Solutions Inc. | 2 North Market Street | Suite #400 | San Jose, CA - 95113

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Email: ... | Web: www.e-solutionsinc.com

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Disclaimer: E-Solutions provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. We especially invite women, minorities, veterans, and individuals with disabilities to apply. EEO/AA/M/F/Vet/Disability

Clinical Documentation Specialist1clinical, Inpatient, concurrent, ("RHIA" OR "RHIT" OR "CCS) United States