Advanced Clinical Documentation Specialist RN

Advanced Clinical Documentation Specialist RN

Join a dynamic healthcare team as an Advanced Clinical Documentation Specialist, focusing on enhancing the accuracy and completeness of clinical records. This role involves detailed concurrent reviews and collaboration with physicians, nursing staff, and interdisciplinary caregivers to ensure documentation supports appropriate acuity, resource utilization, quality, and reimbursement.

Education and Formal Training: Preferred candidates will have graduated from an accredited program and hold an active, unencumbered nursing license (RN) under a Nursing Licensure Compact or possess a medical/osteopathic doctorate (MD/DO). Internationally qualified physicians (IMD/MBBS) may also be considered. This position does not require direct patient care.

Experience: A minimum of five years of recent clinical experience in a hospital setting is required, including at least one year in critical care areas such as the Emergency Department or ICU. Alternatively, candidates with four years of hospital experience while pursuing a medical/osteopathic degree, two years of ICD-9/10 coding experience, one year as a Clinical Documentation Improvement Specialist, or two years in Utilization Review are preferred.

Skills and Abilities: The ideal candidate demonstrates excellent observation, critical thinking, and problem-solving skills, along with strong verbal and written communication abilities. Proficiency with basic computer applications, including Microsoft Windows, is necessary. This role requires handling sensitive information with confidentiality and communicating effectively with diverse professional teams. A calm demeanor under pressure and a team-oriented attitude are essential.

Physical Requirements: Some light lifting and occasional walking throughout the facility are expected. Near visual acuity is needed for proofreading documents, along with manual dexterity to operate office equipment. The position may involve exposure to blood or other potentially infectious materials.

This opportunity is based in a regional healthcare setting serving the Southeastern United States, offering a supportive environment dedicated to quality patient outcomes and professional growth.