Job Description

Job Description

Job Description

Job Title: Clinical Documentation Specialist

Location: Remote (Locals required for Onsite Orientation which could take a couple of weeks)
Shift Schedule: 5 Shifts per Week, 7:30 AM to 4:00 PM PST (Flexible start times as early as 6 AM PST)
Anticipated Assignment Length: 13 Weeks with Possible Extension
Dress Code: Professional

Job Description:

We are seeking a Clinical Documentation Specialist. As a Clinical Documentation Specialist, you will play a key role in ensuring the quality and accuracy of clinical documentation in healthcare records. This role requires an experienced individual who can work both independently and as part of a collaborative team. You will be responsible for performing documentation validation reviews, both concurrently and retrospectively, to ensure compliance with industry standards and coding requirements. The Clinical Documentation Specialist will also support the denial/appeal process for DRG challenges and clinical validation of claims.

While the role is remote, candidates must be able to attend onsite orientation for the first couple of weeks. Additionally, you will need to provide your own computer equipment (laptop, monitors, camera/headsets), though the facility will install all necessary programs for the role.

Responsibilities:

• Perform clinical documentation validation reviews for both concurrent and retrospective records.

• Review physician queries to ensure that documentation is accurate, consistent, and complete.

• Identify educational opportunities and discrepancies in clinical indicators and diagnostic statements that impact DRG assignment, severity of illness, risk of mortality, and resource utilization.

• Support clinical denial/appeal processes, specifically addressing DRG downgrades.

• Assist in the clinical documentation specialist and physician leadership through data analysis, dashboards, and audits.

• Act as a subject matter expert and resource for clinical documentation specialists, and assume the role of CDS when required.

Hard Requirements:

• Licensure: RN, LVN, IMG/FMG

• Education: Associate or Bachelor’s Degree in Clinical Documentation or related field.

• Certification: CCDS, CCS, CDIP certifications preferred (not mandatory if the candidate has significant Clinical Documentation experience).

• Experience:

  • 3-5 years of clinical documentation experience in the Clinical Documentation field (must be specific to Clinical Documentation).

  • Experience using Power Chart (Cerner), 3M 360, Midas, and proficient knowledge of APR and MS DRG methodology.

  • Proven ability to review denials, create, and submit appeal letters related to DRG downgrades.

  • Knowledge in Trauma, NICU, and Obstetric Service Lines strongly preferred.

  • Familiarity with HCC knowledge and other risk adjustment methodologies (e.g., Vizient, Elixhauser).

  • Experience with PSI/HAC and clinical coding.

Soft Skills:

• Strong analytical skills and attention to detail.

• Excellent written and verbal communication skills.

• Ability to work independently and as part of a team.

• Strong organizational skills and the ability to manage multiple tasks simultaneously.

• Flexibility to handle variable work schedules, including weekends, on-call, and holidays.

• Problem-solving ability with a proactive approach to identifying and addressing documentation gaps.

Preferred Skills:

• No specific preferred skills; however, any experience working with Clinical Documentation teams or in clinical documentation management will be considered an asset.

How to Apply:
If you meet the qualifications and are ready to contribute to an essential role in the healthcare field as a Clinical Documentation Specialist , we encourage you to apply! We look forward to hearing from you and discussing how your skills can make a difference in this role.

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