Clinical Documentation Maestro: Accurate Coding & SOI

Brown Medicine; United States; On-site; USD 87,000 - 174,000; Full time

Job summary

Brown University Health is seeking a Clinical Documentation Specialist to perform concurrent medical record audits and improve documentation quality to reflect severity of illness, risk of mortality, and care complexity. You will collaborate with physicians, mid-level providers, nursing staff, and coding teams to ensure accurate, complete documentation and DRG assignment.

Ideal candidates hold RI RN license (BSN required, master’s preferred) or Physician Assistant/NP licensure with

Qualifications

• Licensed RN in Rhode Island (Nurse Licensure Compact accepted).
• 3 years of clinical experience; BSN required; master’s degree preferred.
• PA or NP licensure with RI license and CDS experience, or eligibility for medical degree with CDS experience.

Responsibilities

• Conduct concurrent auditing of the medical record to ensure documentation reflects severity of illness, risk of mortality, and care.
• Identify documentation gaps and opportunities to clarify incomplete or conflicting entries.
• Develop concise, compliant written and verbal queries and discuss patient care with physicians/mid-level providers.
• Provide just-in-time education to physicians/mid-level providers regarding documentation requirements.
• Maintain CDI database and perform DRG reconciliation to ensure accurate DRG and diagnoses.
• Collaborate with coding staff to resolve discrepancies; act as clinical liaison between HIM Coding Staff and physicians.
• Meet productivity targets for record review (Year 1–2: 16–22 per day; Year 2+: 20–24 per day).

Skills

Clinical documentation

DRG reconciliation

Communication with physicians

Coding liaison

Education

RI RN license

BSN

Master's degree preferred

PA licensure

NP licensure

Medical degree with CDS experience

Tools

3M encoder

Job description

Brown University Health is seeking a Clinical Documentation Specialist to perform concurrent medical record audits and improve documentation quality to reflect severity of illness, risk of mortality, and care complexity. You will collaborate with physicians, mid-level providers, nursing staff, and coding teams to ensure accurate, complete documentation and DRG assignment.

Ideal candidates hold RI RN license (BSN required, master’s preferred) or Physician Assistant/NP licensure with