Clinical Documentation Specialist

A company is looking for a Clinical Documentation Specialist I to support value-based care and ensure accurate documentation of clinical conditions and procedures.

Key Responsibilities

Determine principal and secondary diagnoses and assign appropriate working DRGs based on medical record reviews

Educate providers to enhance diagnostic specificity and maintain compliance with documentation standards

Utilize CDI software tools to manage review activities and meet performance targets

Required Qualifications

High School Diploma / GED or equivalent

Five years of experience as a clinical nurse in a high acuity department or as an inpatient / outpatient coder, or two years as a Clinical Documentation Integrity Specialist

Associate's Degree in a healthcare-related field (preferred)

Registered Nurse (RN) license in the current state of employment (preferred)

Experience with ICD10-CM, CPT, HCC, and HCPCS coding (preferred)