RN Clinical Documentation Specialist

Job Summary

A company is looking for an RN Clinical Documentation Specialist to facilitate and obtain appropriate physician documentation for patient clinical conditions.

Key Responsibilities:

• Conducts initial and ongoing patient medical record reviews and documents findings in the CDE software system
• Assigns principal diagnoses, evaluates severity of illness and risk of mortality, and codes using ICD-10-CM and PCS
• Educates healthcare providers on clinical documentation improvement and collaborates with coding professionals to ensure documentation accuracy

Required Qualifications:

• Current RN Licensure
• Minimum of five years of acute care nursing experience in medical/surgical, Intensive Care, or Emergency Department
• CRCR certification required within 9 months of hire
• Proficient in using CDE software and coding systems
• Strong interpersonal skills with the ability to interact effectively with physicians and healthcare staff