
Clinical Documentation Improvement Specialist
13 hours ago
In this role, you will be responsible for evaluating patient medical records to ensure they meet the highest standards of accuracy and completeness. A strong understanding of clinical documentation principles and the ability to analyze complex medical information with precision are essential.
Main Responsibilities:- Evaluate patient records for clarity, completeness, and consistency in clinical documentation.
- Analyze diagnoses, treatments, and care documentation for accuracy and adherence to established standards.
- Flag documentation gaps, inconsistencies, or ambiguities for clarification and improvement.
- Collaborate with internal teams to provide feedback and support documentation improvement initiatives.
- Ensure compliance with internal standards, HIPAA regulations, and external quality and audit requirements.
- Monitor documentation trends and contribute to internal reviews and quality improvement initiatives.
- Maintain confidentiality and attention to detail in all documentation processes.
- Work independently with a focus on record review, devoid of direct patient communication.
- Bachelor's degree in Nursing, Health Information Management, or a related healthcare field.
- Minimum 2 years of experience in clinical documentation review, medical records, or healthcare quality.
- Strong clinical knowledge and understanding of medical terminology and care workflows.
- Fluent in English (spoken and written) with excellent communication and documentation skills.
- Comfortable working in an evening shift environment, 6:00 PM to 2:00 AM, 6 days a week.
- Proficient in using Electronic Health Record (EHR) systems.
- Certification in Clinical Documentation Improvement (CCDS, CDIP) is highly desirable but not required.
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