Clinical Documentation Specialist

AGS Health
Olyphant, Pennsylvania, United States (remote)
12 days ago


Facilitates and obtains appropriate clinical documentation for all clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care provided

Responsible for concurrent inpatient medical record reviews for Medicare, Medicaid and all commercial payers

Generates queries and have follow up discussions with physicians for clarification of ambiguous or conflicting documentation
Facilitates modifications to clinical documentation supporting appropriate reimbursement is received for the level of service rendered to all patients
Demonstrates knowledge of payor issues, documentation opportunities, clinical documentation requirements, and referral policies and procedure
Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation (CD) guidelines
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and Hospital outcomes
Educates medical and coding staff on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart; reviews clinical issues with coding staff
Operates under general guidance and work assignments are varied and require interpretation and independent decisions on course of action



Bachelors degree in Health Information Management, Nursing or related field

Must have one of the following credentials: - AHIMA (American Health Information Management Association) certification -  ACDIS (Association of Clinical Documentation Improvement Specialists) certification - RN (Registered Nurse) license -

For Inpatient Clinical Documentation Specialist, three (3) years of inpatient facility medical coding, acute inpatient direct patient care, or inpatient Clinical Documentation Specialist experience

Strong knowledge of medical record documentation requirements and coding guidelines in accordance with third party payer, state and federal regulations, or strong acute/ambulatory care clinical knowledge of clinical indicators, disease processes, and treatment

Must possess strong communication skills, both written and verbal

Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills

Strong critical thinking and sound judgement in decision making

Job Information

  • Job ID: 70817803
  • Workplace Type: Remote
  • Location:
    Olyphant, Pennsylvania, United States
  • Company Name For Job: AGS Health
  • Position Title: Clinical Documentation Specialist
  • Industry: Vendor/ Professional Services
  • Job Function: CDI/ Clinical Documentation Improvement
  • Job Type: Full-Time
  • Job Duration: Indefinite
  • Min Education: BA/BS/Undergraduate
  • Min Experience: 2-3 Years
  • Required Travel: 0-10%
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