Job Description
**Join Our Team as a Clinical Documentation Specialist!**
We are seeking a dedicated Clinical Documentation Specialist (CDS) to support one of our esteemed clients on a Contract to Hire basis. This role offers the flexibility of 100% remote work, allowing you to work from the comfort of your home.
**Location:** Fully Remote, must be located in a compact license state
**Pay:** $32-52/hr, depending on experience
**Role Overview:**
We are looking for a skilled and committed Clinical Documentation Specialist (CDS) who holds a valid Registered Nurse (RN) license and is certified as either a CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner). In this role, you will play a crucial part in ensuring that clinical documentation is accurate, complete, and compliant, reflecting the quality of care provided and supporting proper coding and reimbursement practices. You will collaborate closely with physicians, clinical teams, and coding professionals to enhance clinical documentation and support patient care.
**Key Responsibilities:**
- Review and assess patient clinical documentation for accuracy, completeness, and adherence to established standards.
- Work closely with healthcare providers to resolve unclear or incomplete documentation.
- Educate physicians and clinical staff on best practices for documentation, emphasizing the role of accurate documentation in coding and reimbursement.
- Perform both concurrent and retrospective medical record reviews to identify opportunities for improving documentation.
- Ensure compliance with regulatory guidelines and organizational policies related to clinical documentation and coding.
- Track and report clinical documentation performance metrics to clinical leadership.
- Stay up-to-date with the latest standards, coding updates, and regulations through participation in training programs.
- Utilize data analysis tools to identify trends in documentation and collaborate with interdisciplinary teams on process improvements.
- Assist in preparing documentation for external audits and support third-party payer or regulatory reviews.
- Contribute to quality improvement efforts by ensuring documentation accurately reflects patient severity of illness and risk of mortality.
**Qualifications:**
- Valid and active Registered Nurse (RN) license (Must be compact)
- CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner) certification required.
- Minimum of 2-3 years of experience in clinical documentation improvement, coding, or related healthcare roles.
- Strong understanding of ICD-10 coding, DRGs, and reimbursement methodologies.
- Excellent communication and interpersonal skills to collaborate with physicians, nursing staff, and coders.
- Ability to work independently and manage multiple priorities in a fast-paced healthcare environment.
- Proficiency in clinical documentation software and electronic health record (EHR) systems.
**Why Join Us?**
- Flexible, 100% remote work environment
- Competitive pay ranging from $32-52/hr, based on experience
- Opportunity to make a significant impact on patient care and documentation quality
If you are passionate about clinical documentation and looking for a role that offers both professional growth and work-life balance, we would love to hear from you!
Employment Type: Full-Time
Salary: $ 32.00 52.00 Per Hour
Job Tags
Hourly pay, Full time, Contract work, Flexible hours,