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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation, ensuring accurate and complete medical records while adhering to ACDIS, AAPC, and AHIMA guidelines. Proficient in utilizing analytical skills and Microsoft products to enhance documentation quality and collaborate effectively with healthcare providers.
Highest-signal resume keywords
Clinical Documentation ExperienceCurrent RN LicenseCCDS or CDIP CertificationAnalytical SkillsMicrosoft Excel Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical DocumentationMedical Record ReviewDocumentation ImprovementDRG Payer KnowledgeQuality MetricsAudit Risk AssessmentHierarchical Condition CategoriesSecond Level Review ExperienceCritical ThinkingPatient Confidentiality
Soft Skills
Effective CommunicationCollaborationEducation and Interaction
Tools & Technologies
Microsoft WordMicrosoft OutlookPC UtilizationMac Computer ProficiencyAI Tools
Certifications & Qualifications
CCDS CertificationCDIP CertificationCurrent RN License
Industry Keywords
ACDIS GuidelinesAAPC GuidelinesAHIMA GuidelinesHIPAA ComplianceHealthcare Documentation
About the role
Key responsibilities & impact- Provide timely reviews of patient medical records to ensure accurate and complete documentation reflecting severity and complexity of illness
- Work with providers and coders to ensure documentation reflects patient complexity
- Educate and interact with providers
- Perform concurrent and/or potential retrospective health record reviews
- Identify opportunities for documentation clarification and improvement
- Collaborate with providers and healthcare professionals using clinical expertise, critical thinking, and coding and regulatory knowledge
- Follow customer-established procedures
- Review assigned medical records for complete and accurate documentation of relevant diagnoses and procedures
- Initiate and complete queries to reflect accurate inpatient or outpatient visit data
- Adhere to ACDIS, AAPC, and AHIMA guidelines
- Maintain strict confidentiality of patient information in accordance with HIPAA
- Apply knowledge of DRG payer issues, audit risks, documentation opportunities, quality metrics, and hierarchical condition categories
- Work closely with clients, co-workers, and management to meet assignment needs
- Utilize computer software according to client requirements
- Travel to field sites may be required up to 15% of the time
Requirements
What you’ll need- 3+ years of clinical documentation experience
- Current RN license
- Strong analytical skills to clinically evaluate the medical record
- Ability to use a PC for medical record review
- Proficiency utilizing Microsoft products (Excel, Word, Outlook)
- Ability to communicate effectively with e4health management and clients
- General understanding and comfort with AI tools
- Comfortable working on a Mac computer
- Full time — at least 32 hours per week
- Applicants for U.S.-based positions must be legally authorized to work in the United States
- Visa sponsorship is not available
- CCDS or CDIP certification preferred
- BSN, in addition to RN license, preferred
- Second Level Review Experience preferred
- PST or MST time zone preferred
Benefits
Comp & perks- $2,000 sign-on bonus
- Full benefits package
- 401(k) with company match
- Medical insurance
- Dental insurance
- Vision insurance
- Life insurance
- Short-term disability insurance
- Long-term disability insurance
- PTO policy