Advanced Clinical Documentation Specialist RN

Advanced Clinical Documentation Specialist RN

Harrells, NC $67,009 - $83,099 a year

Full Time

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, interdisciplinary caregivers, and coding professionals to ensure precise documentation that supports appropriate acuity, resource utilization, quality metrics, severity of illness, 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 environment is required, including at least one year in critical care settings such as the emergency department or intensive care unit. 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 observational and analytical skills, strong problem-solving abilities, and effective verbal and written communication. Proficiency with computers, Microsoft Windows, and keyboarding is necessary. Handling sensitive information with confidentiality and communicating tactfully across diverse professional backgrounds are essential. A calm demeanor under pressure and a team-oriented attitude are highly valued.

Physical Requirements:

This role may involve light lifting and occasional walking throughout the facility. Near visual acuity is needed for proofreading documents, along with manual dexterity to operate office equipment. There is potential exposure to blood or infectious materials.

Work within a supportive healthcare environment serving a broad regional community in the Southeastern United States, dedicated to improving patient outcomes and fostering professional growth.