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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 coding knowledge to improve documentation quality and patient data accuracy.
Highest-signal resume keywords
Clinical Documentation ExperienceRN LicenseCCDS 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 ImprovementCoding KnowledgeCritical ThinkingDRG Payer IssuesAudit RisksQuality MetricsHierarchical Condition CategoriesPatient Visit Data Queries
Soft Skills
Effective CommunicationCollaborationEducation and Interaction
Tools & Technologies
Microsoft WordMicrosoft OutlookPC Utilization
Certifications & Qualifications
RN LicenseCCDS CertificationCDIP Certification
Industry Keywords
ACDIS GuidelinesAAPC GuidelinesAHIMA GuidelinesHIPAA CompliancePatient Confidentiality
About the role
Key responsibilities & impact- Provide timely reviews of patient medical records to ensure accurate and complete documentation reflecting the patient’s 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 as necessary to reflect accurate patient 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 with clients, coworkers, and management to meet assignment-specific needs
- Utilize computer software according to client requirements
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 Excel, Word, and Outlook
- Ability to communicate effectively with e4health management and clients
- Applicants for U.S. based positions must be legally authorized to work in the United States
- Visa sponsorship is not available
- Ability to travel to field sites may be required up to 15% of the time
- CCDS or CDIP certification preferred
- BSN, in addition to RN license, preferred
Benefits
Comp & perks- 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
- Fully remote work arrangement