Clinical Documentation Specialist

Best Care • Omaha, NE

27d • Onsite

About The Position

The Clinical Documentation Specialist is responsible for concurrently reviewing clinical documentation for selected admissions to ensure the medical record accurately represents each patient’s clinical condition through complete and accurate reporting of diagnoses and procedures. The role reviews documentation for incompleteness, ambiguity, conflict, or clinical inconsistency, and determines whether documentation supports the treatment provided. The expected volume is 25–30 reviews per day.

The specialist collaborates with physicians, nurses, care coordinators, utilization management and review staff, inpatient coding staff, and other hospital and health system personnel. The role develops and communicates compliant physician queries, tracks query responses and documentation changes, and supports accurate reporting of patient acuity, quality measures, and case mix index. The specialist also provides education and training to physicians, physician office staff, nurses, and coders in individual, group, and rounding settings.

The position is based at Methodist Hospital, 8303 Dodge St., Omaha, Nebraska, and follows Monday through Friday daytime business hours.

Requirements

• Graduate of an accredited school of nursing.
• Five years of clinical experience in medical-surgical nursing, ICU, case management, inpatient clinical coding, and/or healthcare revenue cycle.
• Current valid Registered Nurse (RN) license, valid compact multistate license, or temporary permit while awaiting licensure.
• Successful completion of annual mandatory education requirements.
• Excellent verbal and written communication and teaching skills.
• Critical thinking skills and knowledge of the healthcare delivery system.
• Ability to develop collaborative relationships with a variety of professionals, including physicians.
• Ability to work as a self-starter and handle resistance and complex situations.
• Ability to foster teamwork and trust.
• Ability to serve objectively and logically as an educator and enabler to physicians.

Nice To Haves

• Bachelor of Science in Nursing (BSN).

Responsibilities

• Concurrently review clinical documentation for selected admissions to ensure it accurately reflects diseases being treated or affecting care, supports treatment provided, and is complete and clinically consistent.
• Assist in developing physician queries that comply with regulatory, legal, and ethical standards and help obtain accurate diagnoses and capture severity of illness.
• Communicate professionally with physicians when documentation is unclear, incomplete, or insufficient to assign ICD-10 codes, using query forms or face-to-face communication.
• Track physician responses to documentation queries and trends such as query compliance, documentation changes, principal and secondary diagnoses, and changes in case mix index.
• Meet regularly with coding staff to clarify documentation requirements and address documentation issues.
• Maintain collaborative relationships with nurses, care coordinators, utilization review staff, inpatient coding staff, and other hospital and health system personnel.
• Provide education and training to physicians, physician office staff, nurses, and coders through one-on-one sessions, group presentations, and brief sessions during rounds.
• Partner with physicians, care coordinators, utilization management, staff nurses, and Coding Specialists to ensure medical records accurately reflect patient acuity for quality reporting and case mix index.

Benefits

• Competitive pay
• Excellent benefits
• Great work environment where all employees are valued

What This Job Offers

• Job Type: Full-time