Clinical Documentation Specialist RN - FT - Days
Vitruvian Health•Dalton, GA
About The Position
The Clinical Documentation Specialist RN reviews patient medical records to determine whether conditions and treatments are documented, ensuring the records provide a clear, accurate, and complete picture of the resources used in care and the complexity of the patient’s condition. The specialist queries physicians when documentation is unclear or deficient and serves as a bridge between Health Information Management, Coding, and clinical staff. The role practices with minimum supervision from another licensed professional and is not patient-facing.
Requirements
- Graduate of an accredited School of Nursing.
- Valid RN nursing license, verified by primary source.
- Three to five years of nursing experience as an RN, including two years of recent clinical experience.
- Computer skills experience required.
Nice To Haves
- Bachelor of Science in Nursing (BSN) preferred.
- Basic Life Support certification through AHA or ARC preferred.
- Utilization Review experience preferred.
Responsibilities
- Review patient medical records to assess whether conditions and treatments are documented.
- Ensure documentation accurately and completely reflects resources used for care and the complexity of the patient’s condition.
- Query physicians when documentation is unclear or deficient.
- Serve as a bridge between Health Information Management, Coding, and clinical staff.
Benefits
- 403(b) matching
- Dental insurance
- Employee assistance program (EAP)
- Employee wellness program
- Employer-paid life and AD&D insurance
- Employer-paid short- and long-term disability
- Flexible Spending Accounts
- ICHRA for health insurance
- Paid annual leave
- Vision insurance
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
