Clinical Documentation Specialist

Nexus Recruitment Group; Pasig; On-site; PHP 420,000 - 600,000; Full time

Job summary

Nexus Recruitment Group is seeking a detail-oriented Clinical Documentation Specialist to join our team. This role reviews, assesses, and ensures the accuracy, completeness, and quality of clinical documentation to support medical billing, coding, and reimbursement processes.

The ideal candidate has strong knowledge of healthcare documentation, coding standards, and regulatory requirements to help clients achieve optimal reimbursement and maintain compliance.

Qualifications

• Bachelor's degree in Nursing, Health Information Management, or related field required.
• 1+ years of experience in clinical documentation review, medical coding, or revenue cycle roles.
• Experience with ICD-10, CPT, HCPCS; familiarity with payer guidelines a plus.
• Strong analytical, communication, and interpersonal skills.
• Attention to detail and ability to manage multiple priorities.

Responsibilities

• Review documentation to ensure accuracy, completeness, and compliance with ICD-10, CPT, and HCPCS.
• Collaborate with physicians and nurses to clarify ambiguous or incomplete notes.
• Identify gaps and propose modifications to support accurate coding and billing.
• Serve as liaison between providers and coders to align documentation with billed services.
• Monitor trends and provide feedback or training to improve quality.
• Assist in audits and compliance reviews to identify risks and improvements.
• Stay updated on payer requirements, CMS guidelines, and documentation best practices.
• Ensure timely review and submission to meet client billing cycles.

Skills

Medical terminology

Analytical skills

Communication skills

Attention to detail

Multitasking

Education

Bachelor's degree in Nursing, Health Information Management, or related field

CDI certification (CCDS/CDIP)

Tools

EHR/EMR systems

Medical billing software

Job description

About the job Clinical Documentation Specialist

Job Summary:

We are seeking a detail-oriented and knowledgeable Clinical Documentation Specialist to join our team. This role is responsible for reviewing, assessing, and ensuring the accuracy, completeness, and quality of clinical documentation in support of medical billing, coding, and reimbursement processes. The ideal candidate will have a strong understanding of healthcare documentation, coding standards, and regulatory requirements to ensure our clients receive optimal reimbursement and maintain compliance.

Key Responsibilities:

• Review clinical documentation to ensure accuracy, completeness, and compliance with industry standards (e.g., ICD-10, CPT, HCPCS).
• Collaborate with physicians, nurses, and other healthcare professionals to clarify ambiguous or incomplete documentation.
• Identify gaps or inconsistencies in documentation and recommend necessary modifications to support accurate coding and billing.
• Serve as a liaison between healthcare providers and coders to ensure documentation supports billed services.
• Monitor documentation trends and provide feedback or training to improve quality and efficiency.
• Assist in audits and compliance reviews to identify areas of risk or improvement.
• Stay updated on payer-specific requirements, CMS guidelines, and documentation best practices.
• Ensure timely review and submission of documentation to meet client billing cycles.

Qualifications:

• Bachelors degree in Nursing, Health Information Management, or related field preferred.
• Certification in Clinical Documentation Improvement (e.g., CCDS, CDIP) is a plus.
• 2+ years of experience in clinical documentation review, medical coding, or healthcare revenue cycle.
• Strong knowledge of medical terminology, anatomy, and disease processes.
• Familiarity with EHR/EMR systems and medical billing software.
• Excellent analytical, communication, and interpersonal skills.
• Strong attention to detail and ability to manage multiple priorities.

Preferred Skills:

• Experience working in a BPO or medical billing outsourcing environment.
• Familiarity with U.S. healthcare billing and insurance systems.
• Ability to work independently and in a team-oriented environment.