Clinical Documentation Specialist RN

7 days ago


Georgia USA, United States Shaker for ChristianaCare Direct Full time
Job Title: 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 inpatient clinical documentation.

Key Responsibilities:
  • Collaborate with program leadership to develop and implement clinical documentation education programs for CDI specialists and clinicians.
  • Track, trend, and audit CDI queries to ensure quality and compliance, identifying knowledge gaps and providing clear explanations.
  • Orient new clinicians and Clinical Documentation Specialists.
  • Create documentation education/references, including clinician-level scorecards, documentation checklists, and tip cards.
  • Participate in weekly huddle education with the coding department.
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, with a self-motivated learner mindset.
  • Completes a minimum of 8 continuing education credits (CEU's) per year in Clinical Documentation Improvement.
Working Conditions:

This is a hybrid position with remote and onsite requirements. The ideal candidate will have strong communication and clinical skills, with the ability to work effectively in a team environment.



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