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Clinical Documentation Specialist RN

1 month ago

Macon, Georgia, United States Shaker for ChristianaCare Direct Full time
Job Title: Clinical Documentation Specialist RN

We are seeking a highly skilled Clinical Documentation Specialist RN to join our team at Shaker for ChristianaCare Direct. As a key member of our clinical documentation team, you will play a critical role in ensuring the accuracy and completeness of patient 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 to our documentation standards.
  • Create documentation education materials, including clinician-level scorecards and documentation checklists.
  • Collaborate with the coding department to provide 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:

This is a hybrid position with remote and onsite requirements. Ability to ambulate within the hospital setting, occasional sitting, standing, and lifting loads of 5-10 pounds. Ability to utilize computer equipment/programs for long periods of time.

Prolonged daily review of charts on computer screen, sitting for extended periods of time.

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