
Documentation Improvement Expert
2 days ago
We are seeking a highly skilled Documentation Improvement Expert to join our team and play a critical role in improving the quality and accuracy of patient medical records.
The ideal candidate will have a strong background in clinical documentation review, medical records, or healthcare quality, with excellent analytical and communication skills.
Responsibilities:- Evaluate patient records to ensure clarity, completeness, and consistency in clinical documentation.
- Analyze diagnoses, treatments, and care documentation for accuracy.
- Identify documentation gaps, inconsistencies, or ambiguities and flag them for clarification.
- Collaborate with internal teams to improve documentation quality and accuracy.
- Support compliance with internal standards, HIPAA, and external quality and audit requirements.
- Track documentation trends and assist with internal reviews or quality improvement initiatives.
**Requirements:**
- Bachelor's degree in Nursing, Health Information Management, or a related healthcare field.
- 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.
- Proficiency in using Electronic Health Record (EHR) systems.
- Certification in Clinical Documentation Improvement (CCDS, CDIP) is a plus but not required.
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