Registered Nurse Clinical Documentation Specialist

Job Summary

Working remotely on a full-time basis, the Registered Nurse Clinical Documentation Specialist will conduct concurrent reviews of inpatient medical records to enhance documentation quality, ensure accurate coding, and collaborate with healthcare providers to support clinical and regulatory compliance.

Key responsibilities:

• Conduct concurrent medical record reviews and assign appropriate diagnoses and procedures
• Collaborate with healthcare professionals to ensure documentation accurately reflects severity of illness and services provided
• Maintain compliance with coding practices and government regulations while educating staff on documentation improvement

Required qualifications:

• Bachelor's degree in Nursing (RN) with current Registered Nurse (RN) licensure, or equivalent medical degree
• Ten years of experience in Clinical Documentation Improvement (CDI) in an acute care setting
• At least one CDI or coding credential/certification (e.g., CCS, CCDS, CDIP, RHIA, RHIT)
• Experience with clinical documentation systems such as Epic and 3M 360 Encoder is preferred
• Three years of experience in Medical/Surgical or Critical Care nursing is preferred