RN Clinical Documentation Specialist
Core
Review medical records to ensure documentation accurately reflects patient acuity, risk of mortality, and resource utilization for billing and quality metrics.
Role type
Clinical Documentation Improvement Specialist
Builds
Accurate clinical documentation and compliant billing data
Domain
Healthcare / Revenue Cycle
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Acute-care clinical experience, Medical record review, DRG assignment, Severity of illness (SOI) assessment, Risk of mortality (ROM) analysis, Documentation clarification queries, Data integrity maintenance, Provider education
Preferred skills
CCDS certification, CDIP certification, CCS certification, CPC certification, Acute clinical documentation program experience
Technologies
Electronic Health Records (EHR), Clinical documentation software
Responsibilities
Conduct concurrent record reviews to identify documentation improvement opportunities, Clarify documentation ambiguities via provider queries, Ensure accurate input of case data and DRG shifts, Report provider and facility outcomes for quality metrics, Educate clinicians on coding and reimbursement issues, Work independently in a remote model with multi-facility responsibility
Seniority
Mid-level, hands-on IC