Non-Clinical - Health and Information Management/Clinical Document Improvement Specialist

Diverse Lynx; Sacramento (CA); Remote; USD 85,000 - 110,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Documentation Specialist (CDS) for a remote position. The role involves reviewing medical records for accuracy and compliance, collaborating with physicians, and ensuring quality care. Candidates should have clinical expertise, strong communication skills, and relevant experience.

Qualifications

• Minimum 2-3 years of Clinical Documentation Specialist experience required.
• CCDS or CCDIP certification required.
• Experience in OBGYN, Pediatrics, Inpatient Psychiatry preferred.

Responsibilities

• Review medical records to ensure accurate documentation.
• Collaborate with healthcare professionals and adhere to regulations.
• Conduct concurrent medical record reviews.

Skills

Quality-based reviews

Mortality reviews

Risk adjustment tool experience

Strong communication skills

Education

Medical degree (IMG) or RN license

Job description

Clinical Documentation Specialist (CDS) – Remote

Contract Duration: 26 weeks (Potential to go perm with facility)
Location: Fully remote, candidates must be based in one of the following states:
Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Illinois, Louisiana, Michigan, Minnesota, Missouri, Montana, Nevada, New Jersey, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington.
(Exceptions may be made for highly qualified candidates outside this footprint only if we have trouble filling with current requirements)

Job Overview:
The Clinical Documentation Specialist (CDS) will utilize their clinical expertise to review medical records, ensuring accurate and complete documentation that reflects the severity of illness and quality of care. The role involves concurrent medical record review, collaboration with physicians and healthcare professionals, and adherence to MS-DRG classification and compliance regulations set by CMS.

Required Qualifications:

Licensure/Education: IMG with a medical degree or RN license.
Experience: Minimum 2-3 years of Clinical Documentation Specialist experience.
Preferred Specialties: Experience in OBGYN, Pediatrics, Inpatient Psychiatry.
Preferred Skills: Quality-based reviews, mortality reviews, and risk adjustment tool experience.
Certifications: CCDS or CCDIP required.
Key Competencies: Strong communication skills, ability to work effectively in a remote team environment.

Recruitment Process:

Application review
Assessment - proctored assessment with the team assistant
Interview
Offer and onboarding