RN Clinical Documentation Specialist

Job Summary

To enhance clinical documentation quality, the full-time RN Clinical Documentation Specialist will work remotely, collaborating with a multi-disciplinary team to ensure comprehensive documentation that accurately reflects clinical treatment, diagnosis, and severity of illness.

Key responsibilities

• Facilitates complete documentation by educating physicians and health team members on complications, co-morbidities, and MS-DRG assignments
• Conducts concurrent and retrospective reviews of patient documentation to ensure accuracy and compliance with standards
• Maintains communication with physicians and HIM coders to clarify documentation needs and improve documentation processes

Required qualifications

• Associates RN, RHIA/RHIT, or Bachelor's Degree with experience/certification in Coding/CDI - Required
• Current RN License - Required
• CCDS certification required after 2 years of experience
• 3-5 years of experience in clinical documentation, coding, or utilization review - Preferred
• Supervisory, education, or leadership experience - Preferred