Registered Nurse Clinical Documentation Specialist

Job Summary

To ensure the overall quality and completeness of medical records, the full-time Registered Nurse Clinical Documentation Specialist will facilitate modifications to clinical documentation through interaction with healthcare providers, support accurate reimbursement processes, and educate the patient care team, all while working remotely.

Key responsibilities

• Facilitates modifications to clinical documentation by collaborating with physicians, nursing staff, and coding personnel
• Ensures timely and accurate documentation of clinical information for measuring physician and hospital outcomes
• Educates patient care team members on documentation practices and compliance with payor requirements

Required qualifications

• Registered Nurse with a BSN or higher preferred
• Minimum of 5 years of experience as a Clinical Documentation Specialist in an acute care setting, preferably at a Level 1 Trauma Center
• Expertise in EPIC EHR and Clintegrity CDE software
• CCDS or CDIP certification required
• Coding certification such as CCS or CRC is preferred