Registered Nurse Clinical Documentation Specialist

Job Summary

Seeking an experienced Registered Nurse Clinical Documentation Specialist, the full-time remote position will manage clinical documentation integrity across inpatient care settings while collaborating with healthcare providers to ensure accurate and complete medical records.

Key responsibilities

• Conduct extensive record reviews to ensure the quality, completeness, and accuracy of clinical documentation
• Educate and communicate with physicians and healthcare staff regarding documentation requirements and best practices
• Collaborate with coding staff to accurately code diagnoses and resolve discrepancies in documentation

Required qualifications

• Associate/Diploma Degree in Nursing or Health Information Technology, or an advanced degree in a medical field
• Current Registered Nurse License, RHIA, RHIT, CCS, or licensure as a PA/NP/APN
• Preferred Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP)
• Two years of experience in Critical Care, Medical or Surgical Inpatient Care Nursing, or as an inpatient coder