The Elite Job is seeking a dedicated Clinical Documentation Specialist to join our dynamic team. This full-time, remote position is ideal for a highly organized individual with a passion for healthcare documentation. In this role, you will collaborate closely with healthcare professionals to ensure accurate, comprehensive, and compliant documentation of clinical records. You will be responsible for reviewing patient files, identifying gaps in documentation, and ensuring that records meet all regulatory and organizational standards. As a remote position, the role provides flexibility and the opportunity to work from anywhere while contributing to the efficiency and accuracy of clinical documentation, improving patient care outcomes.

Your key responsibility will be to ensure that the clinical records support quality patient care, comply with legal and regulatory requirements, and accurately reflect the services provided. You will also act as a liaison between clinical staff and coders, helping to ensure that documentation translates effectively into appropriate coding and billing.

We are looking for a motivated and detail-oriented individual who is ready to make a significant impact on our documentation processes and overall service delivery in healthcare.

Responsibilities:

• Review and analyze clinical documentation to ensure completeness, accuracy, and compliance with healthcare regulations.
• Collaborate with physicians, nurses, and other healthcare providers to improve the quality of clinical documentation.
• Identify gaps in documentation and recommend improvements for clinical staff to ensure compliance with coding and billing standards.
• Ensure that documentation accurately reflects patient diagnoses, treatments, and outcomes.
• Educate clinical staff on best documentation practices to improve patient care and facilitate accurate coding.
• Serve as a liaison between clinical staff and coding/billing departments to ensure effective communication and record accuracy.
• Maintain up-to-date knowledge of clinical documentation requirements, including legal, regulatory, and organizational standards.
• Participate in audits and assist with preparing clinical documentation for audits and reviews.
• Develop documentation templates and guidelines to streamline processes for clinical staff.

Requirements:

• Bachelor degree in Nursing, Health Information Management, or a related field.
• Certification as a Clinical Documentation Specialist (CCDS or equivalent) preferred.
• Strong understanding of healthcare documentation standards, regulatory requirements, and coding systems (ICD-10, CPT, etc.).
• Ability to work independently in a remote setting, with excellent organizational and time-management skills.
• Proficiency with Electronic Health Record (EHR) systems and clinical documentation improvement software.
• Exceptional attention to detail and accuracy in reviewing and analyzing medical records.

Experience:

• Minimum of 3 years of experience in clinical documentation, coding, or related healthcare roles.
• Previous experience working in a remote environment is a plus.
• Experience working with healthcare professionals to improve clinical documentation quality.

Working Hours:

• Full-time position with standard working hours of 40 hours per week.
• Flexible working hours, with some overlap required for team collaboration.

Knowledge, Skills, and Abilities:

• Strong written and verbal communication skills, with the ability to communicate effectively with healthcare professionals and administrative staff.
• In-depth knowledge of medical terminology, clinical processes, and healthcare documentation requirements.
• Ability to prioritize tasks and work efficiently under tight deadlines.
• Strong analytical and problem-solving skills, particularly with regard to clinical record accuracy.
• Proficiency in using healthcare-related software systems, including EHR and CDI tools.

Benefits:

• Competitive salary package.
• Full healthcare coverage, including medical, dental, and vision insurance.
• Paid time off, including vacation and sick leave.
• Remote work flexibility, allowing for work-life balance.
• Continuing education and professional development opportunities.
• Retirement savings plan with company contributions.

Why Explore a Career at The Elite Job:

At The Elite Job, we are committed to improving the quality of healthcare through efficient and accurate clinical documentation. Our company offers a dynamic, supportive, and innovative environment where team members are empowered to contribute to impactful healthcare solutions. As a fully remote organization, we embrace flexibility while maintaining a strong sense of community and collaboration. You will have the opportunity to work with top-tier healthcare professionals and use cutting-edge tools to enhance patient outcomes. Join us, and be part of a team that is dedicated to shaping the future of healthcare delivery.

About Company:

The Elite Job is a leading provider of healthcare services and solutions, specializing in clinical documentation and healthcare compliance. Our mission is to streamline healthcare operations by improving the quality and accuracy of clinical records, thus enhancing patient care and ensuring regulatory compliance. We work with a wide range of healthcare providers, from hospitals to private practices, offering expert guidance and services in documentation improvement, coding, billing, and compliance audits.

With a strong commitment to innovation and customer satisfaction, The Elite Job leverages advanced technology and industry expertise to deliver practical solutions that meet the evolving needs of the healthcare sector. Our remote-first culture enables us to attract top talent from across the globe, fostering a diverse and inclusive workforce. We believe in empowering our employees to grow and succeed, offering ample opportunities for professional development and career advancement. At The Elite Job, we are driven by a shared passion for healthcare excellence and are proud to contribute to the future of healthcare delivery through our specialized services.