Clinical Documentation Specialist

Job Summary:

We are seeking a detail-oriented and knowledgeable Clinical Documentation Specialist to join our team. This role is responsible for reviewing, assessing, and ensuring the accuracy, completeness, and quality of clinical documentation in support of medical billing, coding, and reimbursement processes. The ideal candidate will have a strong understanding of healthcare documentation, coding standards, and regulatory requirements to ensure our clients receive optimal reimbursement and maintain compliance.

Key Responsibilities:

• Review clinical documentation to ensure accuracy, completeness, and compliance with industry standards (e.g., ICD-10, CPT, HCPCS).
• Collaborate with physicians, nurses, and other healthcare professionals to clarify ambiguous or incomplete documentation.
• Identify gaps or inconsistencies in documentation and recommend necessary modifications to support accurate coding and billing.
• Serve as a liaison between healthcare providers and coders to ensure documentation supports billed services.
• Monitor documentation trends and provide feedback or training to improve quality and efficiency.
• Assist in audits and compliance reviews to identify areas of risk or improvement.
• Stay updated on payer-specific requirements, CMS guidelines, and documentation best practices.
• Ensure timely review and submission of documentation to meet client billing cycles.

Qualifications:

• Bachelors degree in Nursing, Health Information Management, or related field preferred.
• Certification in Clinical Documentation Improvement (e.g., CCDS, CDIP) is a plus.
• 2+ years of experience in clinical documentation review, medical coding, or healthcare revenue cycle.
• Strong knowledge of medical terminology, anatomy, and disease processes.
• Familiarity with EHR/EMR systems and medical billing software.
• Excellent analytical, communication, and interpersonal skills.
• Strong attention to detail and ability to manage multiple priorities.

Preferred Skills:

• Experience working in a BPO or medical billing outsourcing environment.
• Familiarity with U.S. healthcare billing and insurance systems.
• Ability to work independently and in a team-oriented environment.