Clinical Documentation Specialist-Remote

FlexBoard; India; Remote; INR 900,000 - 1,500,000; Full time

Benefits offered by this job

Medical and dental benefits

Relocation assistance

Tuition reimbursement

Generous time off

Job summary

Mount Carmel seeks a Clinical Documentation Specialist to review and improve documentation, ensuring accuracy and completeness across patient records.

You will educate physicians and care teams, clarify coding and documentation standards, and support initiatives to optimize clinical documentation and patient care quality.

Qualifications

• RN associate/diploma with nursing licensure is required.
• 5–10 years acute care experience is requested.
• Advanced credentials in health information management are considered in lieu of RN.

Responsibilities

• Conduct reviews of patient records for legibility, completeness, and accuracy.
• Ensure severity of illness and services documented reflect care provided.
• Serve as a resource on clinical documentation and coding standards.
• Communicate discrepancies to physicians to clarify documentation.
• Deliver educational sessions on documentation requirements to providers.

Skills

Clinical documentation

Communication

Education delivery

Query management

Interdisciplinary collaboration

Education

Associate/Diploma in Nursing

BSN preferred

Health Information Management degree (RHIA/RHIT)

Tools

ICD-10 coding

DRG methodology

Job description

About the position

Clinical Documentation Specialist utilizes reputed company and coding expertise to reputed company efforts toward the reputed company of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall reputed company, completeness, accuracy, and reputed company of medical record documentation through extensive record review. Through extensive interaction with physicians and other members of the reputed company team, achieves appropriate clinical documentation to support reputed company assignment, medical necessity, severity of illness, risk of mortality, and level of services rendered to reputed company patients. Participates in the development and delivery of education for providers and members of the reputed company team.

What You Will Do

Exhibits reputed company of the Mount Carmel Service reputed company Behavior Standards holding self and others accountable and role modeling reputed company for reputed company to see. For example demonstrates friendliness and courtesy, effective communication creates a reputed company environment and provides first class service. Meets population specific and reputed company other competencies according to department requirements. Promotes a Culture of Safety by adhering to policy, procedures and plans that are in reputed company to prevent workplace injury, violence or adverse outcome to associates and patients. Relationship-based Care Creates a caring and healing environment that keeps the patient and family at reputed company of care throughout their experience at Mount Carmel following the principles of our interdisciplinary care delivery reputed company. (For patient care providers) Provides nursing care, ensures an environment of patient safety, promotes evidence-based reputed company and reputed company initiatives and exhibits professionalism in nursing reputed company reputed company the model of the ANCC Magnet Recognition Program.

Responsibilities

• Conducts reputed company reviews of selected patient records to address legibility, reputed company, completeness, consistency, and precision of clinical documentation.
• Demonstrates understanding of clinical documentation requirements to ensure that the severity of illness, risk of mortality, and services provided are accurately reflected in the record.
• Serves as a resource on appropriate clinical documentation.
• Communicates documentation discrepancies and coding definitions to the physicians both written and verbally as needed to clarify clinical documentation in accordance to query standards and/or policies.
• Conduct 11 educational sessions with physicians and other reputed company team members reputed company to specific documentation requirements.
• Collaborates with the multi-disciplinary team, including physicians, patient care services, case management, coding specialists and other reputed company disciplines regarding clinical documentation issues.
• Utilizes computer systems effectively and maintains record of reviews completed, queries completed and outcome of physician response.
• Participates in the performance improvement activities.
• Attends in-service programs and other activities to promote reputed company reputed company and enhance knowledge in care documentation requirements.
• Attends and reputed company participates in staff meetings, participates in committees as requested.
• Responsible for compliance with Organizational reputed company through raising questions and promptly reporting actual or potential wrongdoing.
• reputed company other duties as assigned.

Requirements

• Associate/Diploma Degree in Nursing and five - ten years acute care medical or surgical experience required.
• reputed company license to reputed company as registered reputed company in the reputed company.
• Minimum of 5 years acute care medical or surgical experience required reputed company-to-haves.
• Bachelor of Science in Nursing preferred.
• A degree in Health Information Management with credentials of RHIA, RHIT, or reputed company with extensive clinical knowledge and a minimum of 5 years inpatient coding experience will be considered in lieu of a RN.
• Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (reputed company) will be considered in lieu of a RN.
• Utilization/Case Management, managed care, or Clinical Documentation and experience in ICD-10 coding conventions and DRG methodology preferred.

Benefits

• Competitive compensation and benefits packages including medical, dental, and reputed company with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous reputed company time off programs.
• Employee recognition programs.
• Tuition/reputed company development reimbursement.
• Relocation assistance (geographic and position restrictions apply).
• Discounted tuition and enrollment opportunities at the .