Senior Clinical Documentation Specialist, PRN (RN required; CCDS or CDIP cert preferred) - REMOTE
Core
Ensures capture of discharge diagnosis and procedures independently; documents patient clinical status and care provided; performs concurrent review of patient records to support assignment of clinical codes.
Role type
Senior Clinical Documentation Specialist (RN)
Builds
Accurate clinical documentation and code assignments for patient discharge
Domain
Healthcare / Medical Records
Required skills
Medical coding, Patient record assessment, Provider communication, Documentation accuracy verification, Co-morbidity identification, Regulatory compliance
Preferred skills
CCDS or CDIP certification
Technologies
Electronic Health Records (EHR) systems
Responsibilities
Assess patient records for accuracy, legibility, and completeness; Communicate with providers regarding missing or unclear clinical documentation; Collaborate with case managers and nursing staff to resolve documentation issues; Monitor provider documentation queries for timely and compliant response; Ensure complete documentation of discharge diagnoses and procedures.