Job Description

Job Description

Job Description

Title : Remote Clinical Documentation Specialist RN

Location : Remote

Duration : 3-month contract

Shift : M-F 8am-5pm PST

Pay Rate: $45/hr

Must Have:

• ASN, BSN preferred
• 2-3 years of Clinical Documentation Integrity experience in an acute care setting
• RN License required upon hire

Plusses:

• 5 years of hospital experience in ICU, ED, or Med-Surg
• 1 year of MS-DRG and APR-DRG assignment experience and/or understanding and experience/understanding of the fundamentals of establishing a DRG
• 1 year of ICD-10 experience and/or understanding

Day To Day:

The Clinical Documentation Specialist conducts thorough reviews of medical records to ensure accurate, complete, and compliant documentation that reflects the patient’s clinical status. They collaborate closely with providers, offering education and feedback through the query process, and partner with coding teams to support accurate ICD-10 and DRG assignment. The CDS also leads documentation improvement initiatives, builds dashboards and reports, and independently manages provider education and performance insights to enhance clinical and financial outcomes.

Job Description:

The Clinical Documentation Specialist (CDS) is responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation. A key success factor of this process is educating providers through the query process and independently supporting them with education and feedback to accurately reflect the patient's true clinical picture within the medical record. In partnering with the coding team, the CDS will be an expert with ICD-10, NS-DRG and APR-DRG assignment.

The CDS's primary responsibility will be to obtain appropriate clinical documentation through extensive review of provider, nursing, ancillary, and other patient caregivers' documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients. The CDS exercises their judgment and discretion to ensure the clinical information utilized in analyzing and reporting outcomes is complete and accurate. On an ongoing basis, the CDS is responsible for supporting the direction and focus of education for providers and the coding staff within their assigned scope of work. The CDS must exercise independent judgment, critical thinking, ability to work independently while interpreting and following CMS guidelines, organizational policies, and procedures.

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