Clinical Documentation RN: Elevate Medical Records & Coding

St. Tammany Health System; Covington (LA); On-site; USD 65,000 - 90,000; Full time

Job summary

St. Tammany Health System seeks a Clinical Documentation Specialist to enhance the accuracy and completeness of patient records.

The CDS collaborates with physicians and care teams to ensure documentation reflects severity, risk of mortality, and complexity of care, aligning with CMS guidelines. The role requires nursing licensure in Louisiana with 5+ years in acute or ambulatory settings and strong coding knowledge.

Qualifications

• Licensed RN in Louisiana with at least 5 years of clinical experience in acute or ambulatory care.
• Knowledge of ICD-10 coding principles and guidelines and risk adjustment coding.
• Proficiency in Microsoft Office applications (PowerPoint, Excel, Word); 3M encoder software experience.
• Excellent written and verbal communication, critical thinking and interpersonal skills.
• Ability to work independently with minimal supervision.

Responsibilities

• Improve the integrity of medical record documentation through interaction with healthcare providers.
• Perform pre-visit and retrospective reviews to support risk adjustment strategy.
• Educate physicians and care teams on documentation guidelines, coding requirements and service-line specifics.
• Collaborate with multidisciplinary teams to ensure accurate DRG capture and HCC coding.
• Apply clinical knowledge to CMS guidelines and drive documentation improvements.

Skills

RN License (LA)

ICD-10 Coding

Risk Adjustment Coding

Microsoft Office

3M Software

Encoder Experience

Communication Skills

Critical Thinking

Interpersonal Skills

Education

Louisiana RN License

BSN (preferred)

Tools

N/A

Job description

St. Tammany Health System seeks a Clinical Documentation Specialist to enhance the accuracy and completeness of patient records.

The CDS collaborates with physicians and care teams to ensure documentation reflects severity, risk of mortality, and complexity of care, aligning with CMS guidelines. The role requires nursing licensure in Louisiana with 5+ years in acute or ambulatory settings and strong coding knowledge.