Position Overview
The RN Clinical Documentation Specialist supports the integrity of clinical documentation through review, education, and consultation. This role works closely with physicians and the healthcare team to improve the quality, completeness, accuracy, and compliance of the medical record.
Key Responsibilities
- Conduct concurrent reviews of patient health records to assess and improve documentation quality.
- Facilitate accurate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality, and level of service.
- Educate physicians, nurses, and other healthcare staff on documentation requirements and improvement opportunities.
- Formulate compliant clarifications and queries using documentation integrity procedures.
- Collaborate with coding staff to ensure diagnoses and comorbidities accurately reflect patient status and care.
- Accurately code relevant and compliant working diagnoses and determine working DRG assignments.
- Use 3M/360 tools to enter CDI-related data and support efficiency and effectiveness tracking.
- Serve as a resource for clinical documentation and resolve discrepancies professionally.
- Perform additional duties as assigned by leadership.
Requirements & Qualifications
Qualifications
- Associate or diploma degree in Nursing or Health Information Technology, or an advanced degree in nursing or a medical field such as NP/APN or PA.
- Active RN license, RHIA, RHIT, CCS, PA licensure, NP/APN licensure, or completion of medical school.
- CCDS or CDIP certification preferred.
- Two years of experience in critical care, medical/surgical inpatient nursing, inpatient coding, or related clinical practice preferred.
- Strong verbal and written communication skills.
- Excellent interpersonal, collaboration, and relationship-building skills.
- Strong critical thinking, prioritization, and organizational skills.
- Ability to deliver effective education and presentations.
- Proficiency with desktop and Windows-based computer systems.
- Accurate data entry and typing skills, minimum 30 wpm.
- Ability to work independently and collaboratively in onsite and virtual environments.
Benefits & Perks
Benefits and Perks
- Full-time day shift
- Strong orientation program
- Generous tuition allowance
- Career development opportunities
- Opportunity to work in a Magnet-recognized hospital
- Supportive mission-driven healthcare environment
Location
New York, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
3 weeks ago