(RN) Clinical Document Specialist/ Full-Time

(RN) Clinical Document Specialist/ Full-Time at Christus Health summary:

The Clinical Document Specialist, a licensed Registered Nurse with at least 5 years of acute care nursing experience, focuses on improving clinical documentation and ensuring compliance with medical coding standards. This role involves analyzing patient medical records, collaborating with physicians to enhance documentation accuracy, and supporting quality and case management processes. Strong communication, computer literacy, and teamwork skills are essential to adapt to dynamic healthcare environments.

Description

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MINIMUM QUALIFICATIONS:

EDUCATION: RN; Graduate of accredited school of nursing . BSN preferred.

CERTIFICATION/LICENSES: Licensed as a Registered Nurse in the State of New Mexico.

SKILLS:

• Basic computer skills in word processing and spreadsheet utilization.
• Excellent written and verbal communication skills.
• Proficient in computer use (desktop and/or laptop).
• Demonstrates basic knowledge regarding HIM coding standards.
• Analytic skills necessary to accurately assess patient medical records.
• Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes.
• Ability to be flexible and adjust to workload/assignment changes and interruptions.

EXPERIENCE: Minimum of 5 years recent experience in an acute care setting in a clinical nursing field required. Prior experience in clinical documentation improvement, utilization review/management, discharge planning, quality management, case management or coding preferred.

NATURE OF SUPERVISION:

-Responsible to: Director of Case Management Services

ENVIRONMENT: Bloodborne pathogen: A

General office environment and general hospital department/nursing units.

PHYSICAL REQUIREMENTS: Ability to walk and stand 80% of work time.

Keywords:

clinical documentation, registered nurse, medical records analysis, clinical coding, patient care, utilization review, quality management, case management, health information management, acute care