Clinical Documentation Improvement Specialist in Alexandria, VA at Apex Life Sciences

Date Posted: 7/12/2018

Job Snapshot

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Job Description

We are seeking a talented Clinical Documentation Specialist to work for a premier health care solutions provider at a Naval base in Portsmouth, VA!  (ICD, Medical Coding, RN, Registered Nurse)

Position Description:

  • Perform initial and follow-up assessments regarding the inpatient provider’s documentation skills to include: verification of patient identification and demographics; reason for admission; disposition date; assignment of diagnoses; procedures documentation and health care provider’s signature.
  • Recognize areas for improvement to certify documentation for measuring and reporting outcomes is accurate and complete.
  • Execute a baseline review of all inpatient health care providers to determine if current Clinical Documentation Improvement Specialists are influencing documentation.
  • Perform a baseline review of all new health care providers within 30 days of seeing patients to determine the current level of documentation detail.
  • Review medical records identified in the task order(s) to identify documentation deficiencies.
  • Conduct inpatient medical record reviews within 24-48 hours of admission.
  • Conduct routine follow-up reviews of the medical record until the issue is resolved
  • Evaluate outstanding queries for provider responses to facilitate timely and accurate documentation.
  • Educate physicians in regards to compliant documentation responsibilities, coding and reimbursement issues and documentation guidelines.
  • Analyze documentation issues to generate and recommend solutions to the Task Order Government POC.
  • Evaluate Present on Admission indicators for diagnosis that could affect the principal diagnosis, quality indicators or MS-DRG assignment.
  • Analyze data to correct identified complex coding deficiencies and improve reimbursement capture.


  • Must be a current or past Registered Nurse (RN)
  • 2-3 years focused on inpatient coding, healthcare and coding regulations including code structure, clinical documentation, MS-DRG experience, criteria-based chart reviews (ex. Utilization Management or Case Management), and quality improvement experience
  • Medical Coding, ICD-10, Inpatient, DCPT, HIPAA compliance 
  • AAPC CCP certified
  • Must be a US Citizen
  • Must have a DOD clearance


For IMMEDIATE consideration, please email your resume to with the subject line “Clinical Documentation”!

EEO Employer

Apex is an Equal Employment Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by law. Apex will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law. If you have visited our website in search of information on employment opportunities or to apply for a position, and you require an accommodation in using our website for a search or application, please contact our Employee Services Department at or 844-463-6178.