Clinical Documentation Specialist

Responsibilities

• Ensure accurate, complete, and compliant clinical documentation to support coding, reimbursement, and quality reporting.
• Review inpatient and outpatient records, clarify diagnoses, and assess severity of illness.
• Collaborate with providers, coders, and revenue cycle teams to optimize documentation.
• Query clinicians as needed to improve documentation quality.
• Use data and analytics to identify documentation trends and educate clinicians.
• Drive process improvements to enhance hospital financial performance and patient financial experience.

Qualifications & Skills

• Clinical expertise as a registered nurse.
• Strong understanding of medical documentation, coding, and compliance standards.
• Excellent communication and collaboration skills.
• Ability to analyze data to inform process improvements.