Southern NH Health System - RN Clinical Documentation Specialist - Revenue Cycle - Full Time

SolutionHealth • Nashua, NH

6d • Hybrid

About The Position

The RN Clinical Documentation Specialist facilitates concurrent documentation of health records to ensure accurate representation of Severity of Illness (SOI) and Risk of Mortality (ROM) for hospitalized patients, resulting in appropriate Diagnosis Related Group (DRG) assignment. This role includes educating healthcare team members on documentation practices that support resource utilization and patient acuity.

Requirements

• Associate degree in Nursing or Health Information Technology required; Bachelor’s degree in Nursing preferred.
• Current NH RN license required; CCDS/CDIP certification preferred.
• Minimum 3 years of nursing experience in an acute care setting OR 3 years of inpatient coding experience required; utilization review/case management experience preferred.
• Strong understanding of pathophysiology, disease processes, and CDI workflows.
• Proficiency in MS Office and EHR systems.
• Excellent oral and written communication skills.
• Ability to interpret clinical data and identify documentation opportunities.

Responsibilities

• Utilize clinical expertise to ensure documentation reflects the appropriate level of service delivered to patients.
• Collaborate with Coding staff and Clinical Documentation Improvement (CDI) team to educate providers on accurate documentation for SOI, ROM, and core measures.
• Perform initial and follow-up medical record reviews using screening guidelines.
• Conduct concurrent reviews of inpatient admissions, assign working DRGs, and clarify documentation with providers as needed.
• Attend patient rounds and collaborate with case management to support medical necessity.
• Maintain databases, generate daily work lists, and track cases from admission through discharge.
• Analyze data for trends and identify educational opportunities for improvement.
• Stay current on coding guidelines and CDI workflows.

Benefits

• Health, dental, prescription, and vision coverage for full-time & part-time employees
• Short-term, long-term disability, life & pet insurance
• Tuition & certification reimbursement (up to $4,000/year)
• Nursing Student Loan Paydown Program (up to $20,000)
• 403(b) Retirement savings plans with company matching
• Continuous earned time accrual & So much more!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees