- Remote
- Remote
- Full-time
- $77K–$116K per year
- 5+ years
Clinical Documentation Specialist
Compensation
Pay Range: $77,313.60 - $115,980.80
Responsibilities
- Examine medical records to ensure documentation is accurate, complete, and reflective of the patient’s clinical status.
- Detect inconsistencies, ambiguities, or missing information in the medical record that may impact coding, compliance, or patient care and request provider clarifications as necessary.
- Verify that clinical documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement and collaborates with the coding/revenue cycle team.
- Ensure that documentation and provider queries align with regulatory standards, including CMS guidelines and organizational policies.
- Communicate and establish relationships with physicians and clinical staff to share insights, trends and education to improve documentation practices.
Requirements
- Doctor of Medicine (MD)
- Doctor of Osteopathy (DO)
- Foreign Medical Graduate (FMG)
- Registered Nurse (RN)
- Pharmacist