Clinical Documentation Specialist

Job Title: - Clinical Documentation Specialist Job Location: - 100% Remote Job Duration: 6+ months (Temp to Perm) Pay Range: $67.00hr. to $67.80/Hr. on W2 Shift: Day 5x8-Hour (08:00 AM - 05:00 PM) PST Time Job Description: 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.

Review and analyze medical records for accuracy and completeness, ensuring compliance with HIPAA regulations. Collaborate with healthcare providers to enhance patient care documentation, focusing on inpatient cases, including Pediatrics and Ob/Gyn. Utilize EHR systems to maintain and update patient information, ensuring proper coding with ICD-9 and CPT standards. Communicate effectively with multidisciplinary teams to facilitate discharge planning and improve documentation practices. Stay current with medical terminology and documentation standards to support quality patient care.