Remote Clinical Documentation Specialist

UCHealth; South Dakota; Remote; USD 106,191,000 - 164,589,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Tuition reimbursement

Performance bonus and merit increases

Job summary

UCHealth is seeking a Clinical Documentation Specialist to perform concurrent review of medical records to ensure compliant, accurate reimbursement based on severity of illness, risk of mortality, and level of services provided. You will collaborate with physicians, nursing, coding, and other staff to ensure documentation is complete and accurate.

This 100% remote role accepts out-of-state candidates. Requires RN/BSN/NP/PA/MD and licensure, with 5 years of acute inpatient experience or CDI

Qualifications

• Graduate of an accredited Registered/Professional Nursing program (RN/BSN) or advanced practice degree (NP/PA/MD).
• US-accredited programs accepted for international graduates.
• Current RN/NP/PA license; MD/DO allowed without active RN/NP/PA licensure.

Responsibilities

• Reviews inpatient records to document diagnoses/procedures and assign DRG.
• Identifies need to clarify documentation; communicates with providers.
• Performs follow-up reviews for physician queries.
• Collaborates with coding staff to ensure accurate reflection of patient status.
• Maintains knowledge of changing requirements and guidelines.
• Demonstrates critical thinking and works with minimal supervision in fast-paced settings.

Skills

Clinical Documentation

DRG assignment

Querying physicians

Collaboration with teams

Education

RN/BSN/NP/PA/MD

State RN/NP/PA license

Job description

UCHealth is seeking a Clinical Documentation Specialist to perform concurrent review of medical records to ensure compliant, accurate reimbursement based on severity of illness, risk of mortality, and level of services provided. You will collaborate with physicians, nursing, coding, and other staff to ensure documentation is complete and accurate.

This 100% remote role accepts out-of-state candidates. Requires RN/BSN/NP/PA/MD and licensure, with 5 years of acute inpatient experience or CDI