RN – Clinical Documentation Specialist

Role Overview

• Communicates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation.
• Utilizes the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes.
• Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues.
• Acts as a consultant to coders when additional information or documentation is needed to assign the correct diagnosis related group (DRG).
• Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team.

Requirements

• Bachelor’s degree in nursing required.
• Graduate from a nationally accredited nursing program preferred, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
• If no degree, will consider seven years equivalent work experience.
• Three years of recent clinical nursing experience required.
• Experience in case management, utilization management, and/or coding preferred.
• Currently holds an unencumbered RN license with the State Board of Nursing.
• Obtains and subsequently maintains required department specific competencies and certifications.
• Certification in Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) preferred.