Position Overview: The Clinical Documentation Specialist (CDS) ensures the accuracy, completeness, and compliance of clinical documentation in healthcare settings. This role involves collaborating with healthcare providers to improve the quality of medical records, supporting accurate coding, billing, and optimal patient care outcomes
Key Responsibilities:
Documentation Review:
Review clinical documentation for accuracy and compliance.
Identify and address documentation gaps and inconsistencies.
Work with healthcare providers to clarify and enhance documentation.
Education and Training:
Train healthcare providers on best documentation practices.
Develop and deliver training materials.
Stay updated on industry standards and regulatory requirements.
Quality Assurance:
Ensure compliance with policies and regulatory requirements.
Participate in audits and quality improvement initiatives.
Monitor and report on documentation quality metrics.
Collaboration:
Coordinate with coding, billing, and quality assurance teams.
Communicate with healthcare providers to resolve documentation issues.
Participate in multidisciplinary meetings and committees.
Documentation Improvement Projects:
Lead or assist in CDI projects and initiatives.
Develop and implement action plans for documentation improvement.
Utilize EHR systems to support documentation efforts.
Qualifications:
Education: Bachelor’s degree in Nursing, Health Information Management, or related field; advanced degrees or CDI certifications preferred.
Licensures: Must hold a valid RN License or be a Registered MD
Experience: 2-3 years in clinical documentation improvement, coding, or healthcare quality.
Certifications: Must have CCDS or CDIP
Seniority level
Associate
Employment type
Contract
Job function
Quality Assurance, Health Care Provider, and Strategy/Planning
Industries
Health and Human Services and Hospitals and Health Care
Referrals increase your chances of interviewing at Medix™ by 2x