- Remote, United States
- Remote
- 5+ years
The Clinical Documentation Specialist (CDS) facilitates the improved integrity of medical record documentation through interaction with healthcare providers to support the appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care.
Responsibilities
- Facilitates improved integrity of medical record documentation through interaction with healthcare providers
- Supports appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care
- Performs pre-visit and retrospective reviews of ambulatory clinical documentation to ensure accurate depiction of patient complexity
- Communicates opportunities and educates members of the patient care team regarding documentation guidelines, coding requirements and service-line specific requirements
Requirements
- Graduate of an accredited School of Nursing
- Bachelor of Science degree in Nursing (preferred)
- Nice to have: Medicare risk adjustment
- Nice to have: Hierarchical Condition Categories (HCC)
- Nice to have: coding