{"schemaVersion":"jobsearcher.job.v1","id":"44b22d9cf3e2f249e5b51c5d","url":"https://jobsearcher.com/jobs/44b22d9cf3e2f249e5b51c5d","canonicalUrl":"https://jobsearcher.com/jobs/44b22d9cf3e2f249e5b51c5d","title":"Clinical Documentation Specialist position","description":"Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.\nFacilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients\nEducates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis\nApplies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities\nAcute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses - obtaining missing information via a query when necessary\n\nClinical Documentation Specialist Qualifications\nMust have at least one of the following:\nLicense to practice as a Registered Nurse preferred (any state)\nCredentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)\nMust have all of the following:\n1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience\nCCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required\n\nAdditional notes:\n\nCandidate must have at least 1 year of experience with concurrent inpatient facility coding/clinical documentation improvement experience. We are looking for someone who has had experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records","company":"Eapps Tech Dba Magicforce","rawCompany":"eapps tech dba magicforce","city":"Raleigh","state":"NC","isRemote":false,"isActive":false,"createdAt":"2026-08-04T21:19:47.858Z","occupations":[{"code":"29-9021.00","title":"Health Information Technologists and Medical Registrars","slug":"health-information-technologists-and-medical-registrars"},{"code":"29-2072.00","title":"Medical Records Specialists","slug":"medical-records-specialists"},{"code":"15-1211.01","title":"Health Informatics Specialists","slug":"health-informatics-specialists"}],"industries":[{"code":"622110","title":"General Medical and Surgical Hospitals","slug":"general-medical-and-surgical-hospitals"},{"code":"621111","title":"Offices of Physicians (except Mental Health Specialists)","slug":"offices-of-physicians-except-mental-health-specialists"},{"code":"621999","title":"All Other Miscellaneous Ambulatory Health Care Services","slug":"all-other-miscellaneous-ambulatory-health-care-services"}],"jobPosting":{"@context":"https://schema.org","@type":"JobPosting","title":"Clinical Documentation Specialist position","description":"Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation in the legal medical record.\nFacilitates necessary documentation in the medical record through extensive interaction with physicians, HIM and coding staff to ensure the most appropriate reimbursement and highest level of SOI/ROM is achieved for the level of service rendered to all patients\nEducates physicians regarding clinical documentation needs, changes to clinical documentation guidelines and coding and reimbursement opportunities on an on-going basis\nApplies knowledge of medical terminology and procedures to evaluate clinical documents for documentation and reimbursement opportunities\nAcute Care (inpatient) medical record monitoring (concurrent) of diagnoses, treatments, and follow-up entries in medical records to validate the accuracy of patient medical record documentation and diagnoses - obtaining missing information via a query when necessary\n\nClinical Documentation Specialist Qualifications\nMust have at least one of the following:\nLicense to practice as a Registered Nurse preferred (any state)\nCredentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist)\nMust have all of the following:\n1-year Acute Care (inpatient) Concurrent Clinical Documentation Specialist experience\nCCDS (Certified Clinical Documentation Specialist - ACDIS) or CDIP (Certified Documentation Practitioner - AHIMA) credential required\n\nAdditional notes:\n\nCandidate must have at least 1 year of experience with concurrent inpatient facility coding/clinical documentation improvement experience. We are looking for someone who has had experience with acute care (inpatient) medical record review (concurrent) of diagnoses, treatments, and follow-up entries in medical records","datePosted":"2026-08-04T21:19:47.858Z","dateModified":"2026-08-04T21:19:47.858Z","hiringOrganization":{"@type":"Organization","name":"Eapps Tech Dba Magicforce","sameAs":"https://jobsearcher.com"},"jobLocation":{"@type":"Place","address":{"@type":"PostalAddress","addressLocality":"Raleigh","addressRegion":"NC","addressCountry":"US"}},"identifier":{"@type":"PropertyValue","name":"JobSearcher","value":"44b22d9cf3e2f249e5b51c5d"},"url":"https://jobsearcher.com/jobs/44b22d9cf3e2f249e5b51c5d"}}