Clinical Documentation Specialist

Talentify; Middletown (CT); Remote; USD 70,000 - 120,000; Full time

Benefits offered by this job

Health insurance

Vision insurance

Dental insurance

401k

Job summary

Actalent is seeking a Fully Remote Clinical Documentation Specialist to improve documentation quality across care teams. You will perform concurrent and retrospective reviews, educate providers, and ensure regulatory compliance while collaborating with physicians, nurses, and other caregivers.

The ideal candidate holds an RN license, CCDS/CDIP certification (CCS if CCDS-2) and 3+ years of nursing experience, with strong EHR skills and excellent communication.

Qualifications

• RN license from any state.
• CCDS or CDIP certification required.
• CCS certification if CCDS-2.
• Minimum of 3 years of clinical nursing experience.
• Strong knowledge of clinical documentation standards and regulatory requirements.
• Excellent communication and interpersonal skills.
• Ability to collaborate with healthcare providers and multidisciplinary teams.
• Proficiency in EHR systems.

Responsibilities

• Facilitate the improvement of clinical documentation by collaborating with physicians, nursing staff, and other patient caregivers.
• Perform concurrent and retrospective reviews of medical records to ensure accurate documentation of patient care.
• Educate healthcare providers on the importance of accurate and complete clinical documentation.
• Utilize clinical knowledge and expertise to identify opportunities for documentation improvement.
• Ensure compliance with regulatory requirements and guidelines.
• Participate in multidisciplinary team meetings to discuss documentation improvement strategies.
• Provide feedback to healthcare providers on documentation practices and areas for improvement.
• Maintain up-to-date knowledge of clinical documentation standards and best practices.

Skills

RN license

Communication

Team collaboration

EHR proficiency

Education

RN license (licensure)

CCDS/CDIP certification

CCS certification

Tools

Electronic Health Records (EHR)

Job description

Fully Remote : Clinical Documentation Specialist

Job Description

Facilitate the improvement of clinical documentation by collaborating with physicians, nursing staff, and other patient caregivers. Perform concurrent and retrospective reviews of medical records to ensure accurate documentation of patient care. Educate healthcare providers on the importance of accurate and complete clinical documentation. Utilize clinical knowledge and expertise to identify opportunities for documentation improvement. Ensure compliance with regulatory requirements and guidelines. Participate in multidisciplinary team meetings to discuss documentation improvement strategies. Provide feedback to healthcare providers on documentation practices and areas for improvement. Maintain up-to-date knowledge of clinical documentation standards and best practices.

Responsibilities

• Facilitate the improvement of clinical documentation by collaborating with physicians, nursing staff, and other patient caregivers.
• Perform concurrent and retrospective reviews of medical records to ensure accurate documentation of patient care.
• Educate healthcare providers on the importance of accurate and complete clinical documentation.
• Utilize clinical knowledge and expertise to identify opportunities for documentation improvement.
• Ensure compliance with regulatory requirements and guidelines.
• Participate in multidisciplinary team meetings to discuss documentation improvement strategies.
• Provide feedback to healthcare providers on documentation practices and areas for improvement.
• Maintain up-to-date knowledge of clinical documentation standards and best practices.

Qualifications

• Registered Nurse (RN) with a current license from any state.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification.
• Certified Coding Specialist (CCS) certification if they have the CCDS 2 certification.
• Minimum of 3 years of clinical nursing experience.
• Strong knowledge of clinical documentation standards and regulatory requirements.
• Excellent communication and interpersonal skills.
• Ability to work collaboratively with healthcare providers and multidisciplinary teams.
• Proficiency in electronic health record (EHR) systems.

Additional Skills

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification.
• Certified Coding Specialist (CCS) certification if they have the CCDS 2 certification.

Work Environment

Fully remote role. Schedule: Monday-Friday 9am-5pm with potential for flexibility as long as 40-hour weeks are maintained.

Pay and Benefits

The pay range for this position is $70000.00 - $120000.00/yr.

Health, Vision, Dental, 401k
If we find a local candidate (CT RN license in CT, they will receive Middlesex Health Benefits, If we find someone national w/o CT RN License then they will receive benefits through 3rd party organization- Mindlance (have been told this is very expensive so they prefer local). Have all the benefit info in a PDF when needed

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on May 9, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [e-mail] for other accommodation options.