Clinical Documentation Medical Professional

Location: United States

Duration: 3 Months

Responsibilities:

• Must be a foreign or domestic Medical School Graduate (license not required) OR graduate from a Physician Assistant or RN Program
• Minimum 3 years of experience in clinical documentation or related medical review role
• Responsible for improving the overall quality and completeness of medical record documentation
• Conducts concurrent and retrospective reviews of inpatient medical records using clinical experience, evidence-based criteria, and protocols
• Facilitates accurate DRG assignment and ensures documentation supports appropriate reimbursement and quality metrics
• Collaborates extensively with physicians, clinical caregivers, and HIM coding teams to obtain and clarify documentation
• Ensures medical records reflect accurate clinical conditions, treatments, and level of care
• Supports education and feedback to providers on documentation best practices and regulatory compliance
• Maintains current knowledge of clinical documentation integrity standards, coding guidelines, and payer requirements
• #LI-Remote
• #LI-JK1