Clinical Documentation Improvement Specialist Senior

Employer Industry: Healthcare Services

• Opportunity for career advancement and growth within the organization
• Work remotely from home in Pennsylvania
• Comprehensive healthcare benefits for full-time and part-time positions from day one, including vision and dental
• Supportive and collaborative work environment that values diversity and inclusion
• Chance to make a positive impact on patient care and clinical documentation

• Review inpatient medical records within 24 to 48 hours of admission to evaluate documentation for accurate diagnosis and procedure assignments
• Pursue subsequent reviews of records every three days to support working DRG assignments upon discharge
• Formulate queries for missing, conflicting, or unclear documentation
• Provide ongoing education to physicians and healthcare providers on clinical documentation improvement
• Collaborate with the interdisciplinary team to resolve documentation queries prior to patient discharge

• Associate's Degree in a Medical/Healthcare Field is required;
  Bachelor's Degree is preferred
• Minimum of 3 years of related work experience in Clinical Documentation Improvement or a similar field
• Current certification as either a Certified Clinical Documentation Specialist, Certified Risk Adjustment Coder, Registered Health Information Technician, or Certified Professional Coder
• Strong analytical thinking and problem management skills
• Proficient in computer literacy and interpersonal communication

• Experience with statistical data analysis and trending for clinical documentation improvement
• Familiarity with training tools for quality documentation and coding improvement
• Previous mentorship or training experience with new staff