Clinical Documentation Specialist

RSD Human Resource Management Consultancy; Philippines; On-site; PHP 520,000 - 760,000; Full time

Job summary

RSD Human Resource Management Consultancy is seeking a Registered Nurse with CCS, CPC, or CDIP certifications to support clinical documentation, medical coding, and quality initiatives. The role combines nursing expertise with coding and documentation standards to improve accuracy and compliance.

Ideal candidates will review medical records, identify documentation gaps, and collaborate with physicians and CDI professionals.

Qualifications

• Must be a Registered Nurse with an active license.
• Must hold CCS, CPC, or CDIP certification.
• Strong knowledge of medical terminology, anatomy, physiology, and clinical documentation.
• Experience in CDI, medical coding, clinical documentation review, or healthcare BPO is preferred.

Responsibilities

• Review medical records and clinical documentation for accuracy and compliance.
• Apply clinical knowledge to support ICD-10-CM/PCS coding and documentation.
• Identify documentation gaps and opportunities for clarification.
• Collaborate with physicians, coders, CDI specialists, and other healthcare professionals.
• Ensure coding and documentation align with regulatory, payer, and organizational requirements.
• Conduct chart reviews and provide recommendations to improve documentation quality.
• Support audits, quality initiatives, and process improvement programs.
• Maintain confidentiality and comply with HIPAA and applicable regulations.

Skills

RN license

Medical terminology

Analytical skills

Attention to detail

Tools

ICD-10-CM/PCS knowledge

Job description

Registered Nurse – Certified Medical Coder / CDI Specialist

Position Overview

We are seeking a highly skilled Registered Nurse (RN) with a CCS, CPC, or CDIP certification to support clinical documentation, medical coding, and healthcare quality initiatives. The ideal candidate combines strong clinical knowledge with expertise in coding and documentation standards.

Key Responsibilities

• Review medical records and clinical documentation for accuracy, completeness, and compliance.
• Apply clinical knowledge to support accurate ICD-10-CM/PCS coding and documentation.
• Identify documentation gaps, inconsistencies, and opportunities for clarification.
• Collaborate with physicians, coders, CDI specialists, and other healthcare professionals.
• Ensure coding and documentation align with regulatory, payer, and organizational requirements.
• Conduct chart reviews and provide recommendations to improve documentation quality.
• Support audits, quality initiatives, and process improvement programs.
• Maintain confidentiality and comply with HIPAA and applicable healthcare regulations.

Qualifications

• Must be a Registered Nurse (RN) with an active license.
• Must hold at least one of the following certifications:
• CCS – Certified Coding Specialist
• CPC – Certified Professional Coder
• CDIP – Certified Documentation Improvement Practitioner
• Strong knowledge of medical terminology, anatomy, physiology, and clinical documentation.
• Working knowledge of ICD-10-CM/PCS, DRGs, and coding guidelines.
• Excellent analytical, communication, and attention-to-detail skills.
• Experience in CDI, medical coding, clinical documentation review, or healthcare BPO is preferred.