RN Clinical Documentation Specialist

Job Summary

To enhance the accuracy and quality of patient records, the full-time RN Clinical Documentation Specialist will perform clinical documentation improvement activities remotely, collaborating with providers and utilizing CDI software to ensure compliance and support continuity of care.

Key responsibilities

• Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy and ensuring proper coding
• Provides education and training to healthcare providers on documentation improvement strategies and compliance standards
• Tracks CDI activities and reports impact metrics while conducting follow-up reviews of patient records for continuous improvement

Required qualifications

• Associate Degree in Nursing or a comparable clinical field is required
• 3-5 years of acute care hospital nursing experience is required
• 3-5 years of experience in clinical documentation improvement or health information management is preferred
• Experience in physician education or query processes is preferred
• Familiarity with regulatory standards and quality metrics related to clinical documentation is preferred