Registered Nurse Clinical Documentation Specialist

Job Summary

Utilizing advanced clinical and coding expertise, the full-time Registered Nurse Clinical Documentation Specialist will ensure the integrity of clinical documentation through extensive record review, education, and consultation, all performed remotely during day shifts.

Key responsibilities

• Facilitates the quality and completeness of medical record documentation through comprehensive reviews and provider education
• Collaborates with healthcare providers to ensure accurate clinical documentation that supports coding and reflects patient care
• Conducts concurrent reviews of patient health records to ensure clarity, completeness, and compliance with documentation standards

Required qualifications

• Associate/Diploma Degree in Nursing or Health Information Technology (HIT) or an advanced degree in a medical field
• Current Registered Nurse License, RHIA, RHIT, CCS, or equivalent medical licensure required
• Two years of experience in Critical Care, Medical or Surgical Inpatient Care Nursing, or as an inpatient coder preferred
• Certification as a Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred
• Proficiency in using standard desktop software and experience with databases and presentation software preferred