RN Clinical Documentation Specialist

Banner Health

Full-time - Mid Level

Remote

Hospitals

About the position

The Clinical Documentation Improvement Specialist plays a crucial role in enhancing the quality of clinical documentation within the healthcare system. This position is responsible for reviewing medical records, clarifying documentation ambiguities, and ensuring compliance with clinical documentation requirements. The specialist acts as a consultant to facility staff and providers, aiming to optimize patient care documentation and capture additional revenue opportunities. This fully remote role requires strong technical skills and self-motivation, with a focus on meeting productivity metrics.

Responsibilities

• Review content of medical records and assist in clarifying documentation ambiguities.
• Act as a consultant and subject matter expert for facility staff and providers regarding clinical documentation requirements.
• Identify and capture additional revenue opportunities through accurate documentation.
• Conduct timely concurrent record reviews to recognize documentation improvement opportunities.
• Ensure data integrity of the clinical documentation database with accurate entries and case reconciliations.
• Educate customers on clinical documentation opportunities and coding issues through presentations and reports.
• Participate in facility task force meetings and other relevant committees.

Requirements

• Registered Nurse (R.N.) license in the state of residence.
• 2-4 years of recent acute care experience in a hospital or surgical setting.
• Strong knowledge of clinical care, preferably obtained through a bachelor's degree in nursing.
• Ability to interface with multiple software applications and work independently.
• Demonstrated critical thinking, problem-solving, communication, and time management skills.
• Ability to work effectively in an interdisciplinary team format.

Nice-to-haves

• Experience with acute clinical documentation programs or coding.
• Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) credential.
• Additional related education and/or experience.

Benefits

• Health insurance coverage
• Financial security options
• Paid time off
• Retirement savings plan options