Clinical Documentation Specialist

1 week ago


Newark, Delaware, United States ChristianaCare Full time
Job Summary

ChristianaCare is seeking a skilled Registered Nurse to fill the role of Clinical Documentation Specialist. This position will be responsible for improving the overall quality and completeness of clinical documentation within the inpatient medical record.

The ideal candidate will have a strong background in nursing and experience in clinical documentation, case management, or performance improvement. They will be able to work efficiently independently and as part of a team, demonstrating diplomacy and tact in all interactions.

Key Responsibilities:

  • Concurrent review of inpatient medical records to identify potential gaps in physician documentation.
  • Communication with physicians and other providers to validate observations and prompt for documentation as needed.
  • Application of HIMS standards of coding to ongoing evaluation of medical record documentation.
  • Identification of patients appropriate for Hospital Quality Measures and prompting of RN and physician for clinical documentation.
  • Education of physicians and other key healthcare providers on clinical documentation improvement and the need for accurate and complete documentation.

Requirements:

  • Bachelor's degree in nursing.
  • DE RN licensed or RN Compact State License.
  • Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting preferred.
  • RN experience in Cardiac, Critical Care, Med-Surg, and Oncology experience highly desirable.
  • Clinical Documentation, Case Management, Performance Improvement, or Inpatient Coding experience highly desirable.
  • Certified Clinical Documentation Specialist (CCDS) certification required within a year of eligibility.

Working Conditions:

Nursing Unit Environment – no patient contact. Normal Office Environment.

Frequent deadline situations.

ChristianaCare is an organization that puts patients first, delivering care to our community through our clinical providers and logistical support team. We invite you to join us in our quest for excellence.

Benefits:

  • Holiday Pay
  • Guaranteed Hours
  • Continuing Education
  • 403b retirement plan
  • Pet insurance
  • Cancelation protection
  • Wellness and fitness programs
  • Mileage reimbursement
  • Employee assistance programs
  • Medical benefits
  • Dental benefits
  • Vision benefits
  • Benefits start day 1
  • License and certification reimbursement
  • Life insurance
  • Discount program


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