RN Clinical Documentation Specialist

Established in 2000, LanceSoft is a pioneer in delivering top-notch Global Workforce Solutions and IT Services to a diverse clientele. We pride ourselves on fostering global cross-cultural connections that advance both the careers of our employees and the success of our clients' businesses. At LanceSoft, our mission is clear: to leverage our global network to seamlessly connect businesses with the right talent and individuals with the right opportunities, all without bias. We believe in providing Global Workforce Solutions with a personalized, human touch. Our comprehensive range of services spans various domains, encompassing temporary and permanent staffing, Statement of Work (SOW) arrangements, payrolling, Recruitment Process Outsourcing (RPO), application design and development, program/project management, and engineering solutions. Currently, our team of over 5,000 professionals caters to 110+ enterprise clients worldwide, including Fortune companies. Our client base represents a diverse spectrum of industries, including Banking & Financial Services, Semiconductor/VLSI, Technology, Healthcare & Life Sciences, Government, Telecom & Media, Retail & Distribution, Oil & Gas, and Energy & Utilities. Headquartered in Herndon, VA, LanceSoft operates 32+ regional offices across the North America, Europe, Asia, and Australia. We also have nine delivery centers strategically located in India in Bangalore, Indore, Noida, Baroda, Hyderabad, Bhubaneshwar, Dehradun, Goa, and Aligarh to further enhance our client service capabilities.

The Clinical Documentation Specialist is an experienced Clinical Documentation Nurse who has obtained knowledge and expertise in all patient populations across the enterprise to provide comprehensive Clinical Documentation Integrity (CDI) chart reviews. Facilitates modifications to clinical documentation to ensure appropriate reimbursement is received for the level of service rendered. Ensures the accuracy and completeness of clinical information used for measuring and reporting clinical and quality outcomes.

Collects and assesses data within CDI software systems. Independently applies experience and critical thinking skills to identify opportunities for documentation improvement that support the program and organizational goals. Facilitates modifications to clinical documentation to ensure appropriate reimbursement is received for the level of service rendered. Improves quality and completeness of clinical documentation by performing initial, follow-up, reconciliation reviews while adhering to organizational workflows and ACDIS / AHIMA guidelines. Provides training and guidance to Associate CDS nurses. Identifies and reviews complex clinical issues / service line trends upon reconciliation process via level process with coding. Facilitates and enhances procedural coding practices. Collaborates with physicians, midlevel providers, nursing staff, other patient providers, and coding staff to ensure appropriate reimbursement is received for the level of service rendered and to capture Quality specific codes related to patient encounter specific DRG’s. Ensure points of clarification have been recorded in the patient’s chart. Maintains records that support appropriate financial reimbursement (DRG and CMI) and organization quality benefit rankings. Other duties as assigned.