Clinical Documentation Specialist (Medical)

TL;DR

Clinical Documentation Specialist (Medical): Ensuring the integrity and accuracy of medical record documentation through extensive review and provider education with an accent on severity of illness and quality indicators. Focus on conducting concurrent reviews and formulating compliant clinical queries to ensure precision in health records.

Location: Remote (Must be based in the US; specific locations listed: Davenport, Monticello, Clinton, Waterloo, Newton, or Des Moines, Iowa)

Company

A healthcare system dedicated to providing compassionate, person-centered care rooted in its mission and core values.

What you will do

• Review medical records to ensure severity of illness, risk of mortality, and quality indicators are accurately reflected.
• Educate physicians and other healthcare team members on clinical documentation standards.
• Conduct concurrent reviews of patient health records for legibility, clarity, completeness, and consistency.
• Formulate compliant clarifications and queries following documentation integrity procedures.
• Monitor provider engagement and incorporate organizational mission and values into daily practices.

Requirements

• Associate/Diploma Degree in Health Information Technology (HIT), an Advanced degree in nursing (NP, APN), or Physician Assistant certification.
• Alternatively, a minimum of 3 years of experience as an inpatient code or documentation specialist.
• Must be based in or associated with the specified Iowa locations.
• Strong critical thinking, interpersonal, and relationship-building skills.
• Proficiency with Windows-based computer systems and a minimum typing speed of 30 wph.

Nice to have

• Certifications such as RN, RHIA, RHIT, CCS, CCDS, or CDIP.
• Experience in critical care, medical, or surgical inpatient care nursing or inpatient coding.

Culture & Benefits

• Commitment to diversity, equity, and inclusion as an Equal Opportunity Employer.
• Work environment rooted in Mission, Vision, and Core Values.
• Focus on person-centered care and professional collaboration.