Clinical Documentation Specialist RN
Core
Improves the quality and completeness of clinical documentation by performing chart reviews, clarifying information with physicians, and assigning accurate principal diagnoses and DRGs to reflect clinical acuity.
Role type
Senior Clinical Documentation Specialist (RN)
Builds
Accurate medical records and compliant DRG assignments for hospital patients
Domain
Healthcare / Clinical Documentation Improvement
Required skills
Adult medical/surgical nursing experience, ICU or PACU experience, BSN degree, 5+ years nursing experience, ICD-10 coding knowledge, DRG assignment, clinical documentation improvement (CDI) principles, physician communication, data analysis
Preferred skills
CDI certification, pediatric clinical experience (for associates), performance improvement strategy development
Technologies
ICD-10 coding system, DRG classification, hospital electronic health records
Responsibilities
Review clinical charts for accuracy and completeness; Confer with physicians to clarify missing or conflicting documentation; Identify appropriate principal diagnoses and complications; Coordinate education for staff on documentation standards; Track trends and performance measures; Report safety issues through established channels
Seniority
Senior, hands-on IC
