Clinical Documentation Specialist (RN) (Days)

Tanner Health System • Carrollton, GA

452d

About The Position

The Clinical Documentation Improvement Specialist (RN) plays a crucial role in enhancing the quality of clinical documentation through thorough medical record reviews, provider queries, and education. This position ensures that documentation accurately reflects the severity of illness and resource utilization, thereby supporting compliance with regulatory requirements and optimizing hospital and physician profiles. The specialist's work contributes to correct reimbursement, reduction of denials, and improved patient care.

Requirements

• Georgia-licensed RN with 5+ years recent adult ICU or adult medical-surgical experience, or equivalent combination of credential and experience.
• Minimum Associate Degree; Bachelor's degree preferred.
• Two years of related experience with working knowledge of specialized practices, equipment, and procedures.
• Proficient in Microsoft Word, Excel, and PowerPoint; experience with electronic medical records preferred.
• Excellent organizational and time management skills, outstanding analytical skills, and strong clinical thinking skills.
• Excellent written, verbal, and communication skills.

Nice To Haves

• CCDS or CDIP credential strongly preferred but not required.
• RHIA or RHIT with CCS or CPC credential with 2+ years acute care inpatient coding experience.
• RHIA or RHIT without coding credential with 3+ years acute care inpatient coding experience.
• Experience as a full-time clinical documentation specialist in a full-service acute care hospital.

Responsibilities

• Assigns working DRG during concurrent review and reconciles it with the final DRG assigned by the HIM coding team after discharge.
• Works closely with the HIM coding team to ensure the final DRG selected accurately represents severity of illness and resource utilization.
• Completes initial review of assigned medical records per departmental policy.
• Records review data using current clinical documentation software.
• Delivers multifaceted education to providers regarding relevant issues and topics in clinical documentation.
• Offers education to other healthcare workers regarding relevant issues and topics in clinical documentation.
• Queries providers to obtain clarification of documentation as needed, in accordance with departmental query policy.
• Reviews assigned medical records for documentation issues such as conflicting, imprecise, incomplete, or ambiguous information.
• Collaborates with other healthcare team members to improve documentation and prevent denials.
• Conducts follow-up reviews per departmental policy and documents results using clinical documentation software.
• Identifies and reports issues impacting the effectiveness of the Clinical Documentation program.

Benefits

• Health insurance coverage
• Paid time off
• Retirement savings plan
• Continuing education support

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree