Clinical Documentation Specialist RN

2 weeks ago


Augusta, Georgia, United States Shaker for ChristianaCare Direct Full time
{"title": "Clinical Documentation Specialist RN", "content": "Clinical Documentation Specialist RN

Shaker for ChristianaCare Direct is seeking a skilled Clinical Documentation Specialist RN to support the documentation process and improve the quality of clinical documentation. As a key member of our team, you will work closely with clinicians and CDI staff to ensure accurate and complete documentation.

Key Responsibilities:

  • Develop and implement clinical documentation education programs for CDI specialists and clinicians.
  • Track, trend, and audit CDI queries to ensure quality and compliance.
  • Orient new clinicians and CDI specialists.
  • Create documentation education/references, including clinician-level scorecards and documentation checklists.
  • Collaborate with the coding department for weekly huddle education.

Requirements:

  • Bachelor's degree in nursing.
  • DE RN licensed or Compact Nursing License.
  • Strong medical terminology and clinical awareness.
  • Effective communication and clinical skills.
  • Clinical Documentation Certification (CCDS) required within 1 year of eligibility.
  • Minimum of 3 years CDI experience, with a focus on PSIs preferred.
  • Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting preferred.
  • Promotes a culture of continuous improvement and learning, self-motivated learner.
  • Completes a minimum of 8 continuing education credits (CEU's) per year in Clinical Documentation Improvement.

Working Conditions:

Limited patient contact, normal office environment, possible remote work opportunities.

"}

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