Providing clinically based concurrent and retrospective reviews of inpatient medical records, the part-time State Licensed Clinical Documentation Specialist will evaluate documentation and utilization of acute care services to ensure accurate physician documentation and compliance for reimbursement.
Key responsibilities:
Conduct concurrent and retrospective reviews of inpatient medical records to assess documentation quality and compliance
Facilitate appropriate physician documentation to reflect patient severity of illness and risk of mortality
Collaborate with external payers and regulatory agencies to meet documentation requirements and improve quality of care outcomesRequired qualificationsBachelor's degree in Nursing or Health Information Management, or equivalent experience
Current RN or CCS license; CCDS or CDIP preferred
Minimum of 6 years of related clinical experience, including inpatient case management or coding
Strong knowledge of care delivery documentation systems and medical record documentation
Ability to work independently in a time-oriented environment and maintain effective physician communication
