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Clinical Documentation Specialist RN
2 months ago
We are seeking a highly skilled and experienced Registered Nurse (RN) to fill the role of Clinical Documentation Specialist RN at CommonSpirit Health. This is a unique opportunity to join our team and contribute to the delivery of high-quality patient care.
Key Responsibilities- Chart Reviews: Perform thorough chart reviews to ensure that clinical documentation accurately reflects the level of service rendered to patients.
- Discharge Planning: Coordinate discharge plans with the discharge planning team and Primary Care Physician to ensure a smooth transition of care.
- Clinical Documentation Management: Facilitate appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record.
- Education and Training: Provide education and training to new staff, including clinical documentation specialists, physicians, and nursing and allied health professionals, on clinical documentation management best practices.
- Quality Improvement: Identify areas for improvement in clinical documentation and implement strategies to enhance the overall quality and completeness of clinical documentation.
- Education: Associate Degree in Nursing (ADN) or higher.
- Licensure: Current North Dakota RN license.
- Experience: 3-5 years of current clinical experience in an acute care setting.
- Technical Skills: Ability to operate computer programs such as Microsoft Word, Meditech, Med Assets, and Milliman.
- Case Management/Utilization Review Experience: Prior experience in case management or utilization review is preferred.
