Full-Time Clinical Documentation Specialist (RN)

Join Our Team: Clinical Documentation Specialist RN

Are you ready to take your nursing career to the next level? We're seeking a passionate and driven Clinical Documentation Specialist RN to join our dynamic team. If you're looking for an opportunity to make a real impact on patient care while advancing your professional development, this position is perfect for you!

Why Join Us?

• Meaningful Work: As a Clinical Documentation Specialist RN, you'll play a pivotal role in ensuring accurate clinical documentation, directly impacting patient outcomes and quality of care.
• Collaborative Environment: Work alongside physicians, clinicians, and coding staff in a supportive and collaborative environment where your expertise is valued.
• Continuous Learning: We're committed to your growth and development. Receive ongoing education and training to stay up-to-date with the latest clinical documentation and coding guidelines.
• Career Advancement: Take advantage of opportunities for career advancement and professional growth within our organization.

Responsibilities:

• Clinical Documentation Review: Conduct initial, concurrent, and retrospective reviews of medical records to ensure accurate representation of clinical severity, complications, and comorbidities.
• Education and Training: Educate internal staff, including physicians, clinicians, coders, and allied health professionals, on clinical documentation and coding guidelines.
• Relationship Building: Develop and maintain strong professional relationships with colleagues across the organization to facilitate positive program outcomes.
• Compliance and Quality Assurance: Ensure compliance with documentation and coding guidelines, and identify opportunities for performance improvement.
• Professional Development: Continuously enhance your skills and knowledge through ongoing learning opportunities and team collaboration.

Qualifications:

• Education: BSN, CCDS, and CCS preferred.
• Experience: Minimum three years of recent acute care nursing experience required. CDI experience and ICU experience preferred. Clinical expertise required.
• Licensure: RN license required. CCDS, CCS preferred.
• Special Skills: Excellent communication, negotiation, and organizational skills. Ability to work collaboratively and independently. Keen attention to detail and proficiency in using medical records for data extraction.