Clinical Documentation Specialist (RN) - Home Care

St. Jude Children's Research Hospital•Memphis, TN

39d•Hybrid

About The Position

The Clinical Documentation Specialist (RN) supports the Agency's efforts to ensure accurate, complete, and compliant clinical documentation in alignment with regulatory standards and payer requirements. This role performs HIM, utilization review (UR), and clinical documentation review functions, while regularly collaborating with clinical staff to ensure documentation accurately reflects patient condition, services provided, and medical necessity. The position contributes to the Agency's QAPI program through audits, data tracking, and identification of documentation improvement opportunities. This role will be primarily office-based and considered an essential staff member. Limited remote work options. Occasional weekend/holiday responsibilities may be needed. This role may be required to spend time in patient care settings in SJ Housing and patient homes in the community.

Requirements

Bachelor's degree in a relevant field (e.g., nursing).
3+ years of relevant experience in a healthcare setting with familiarity with standards of care, medical record documentation, and exposure to medical terminology.
Must possess a current Tennessee State Board of Nursing license if primary residence is Tennessee or a non-Nurse Licensure Compact state.
Must possess a current State Board of Nursing license in the state of primary residence if the state is a Nurse Licensure Compact state.

Nice To Haves

Master's degree preferred.
3+ years of nursing experience preferred.
2+ years of Home Health experience preferred.
Experience with EMRs in a previous setting preferred.
At least 6 months of experience with Utilization Review responsibilities, QAPI program management, and/or Health Information Management tasks preferred.
Pediatric experience preferred.
Experience with quality improvement, utilization management, risk reduction/safety management, and related issues preferred.
Experience working with accreditation and regulatory standards and their application to patient care preferred.

Responsibilities

Ensures accurate, complete, and compliant clinical documentation in alignment with regulatory standards and payer requirements.
Performs HIM, utilization review (UR), and clinical documentation review functions.
Collaborates with clinical staff to ensure documentation accurately reflects patient condition, services provided, and medical necessity.
Contributes to the Agency's QAPI program through audits, data tracking, and identification of documentation improvement opportunities.