Registered Nurse Clinical Documentation Specialist

Job Summary

To enhance the quality and accuracy of clinical documentation, the full-time Registered Nurse Clinical Documentation Specialist will conduct concurrent reviews of inpatient medical records, collaborate with healthcare providers, and ensure compliance with coding standards, with the possibility of remote work available in approved states.

Key responsibilities

• Conduct concurrent medical record reviews to assign diagnoses and procedures, ensuring ethical and accurate coding practices
• Collaborate with healthcare professionals to ensure documentation reflects the severity of illness and compliance with regulatory standards
• Provide education and support to clinicians and coders regarding documentation improvement and coding compliance

Required qualifications

• Bachelor's degree in Nursing (RN) with current Registered Nurse (RN) licensure, or equivalent medical qualifications
• Ten years of experience in Clinical Documentation Improvement (CDI) in an acute care setting, or relevant certifications
• At least one CDI or coding credential such as CCS, CCDS, CDIP, RHIA, or RHIT
• Experience with clinical documentation systems like Epic and 3M 360 Encoder is preferred