Clinical Documentation Spec

CoxHealth; Springfield (MO); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical

Vision

Dental

Retirement with Employer Match

Job summary

CoxHealth is seeking a Documentation Improvement professional at West Campus in Springfield, MO. The role focuses on timely, accurate physician documentation and interdisciplinary collaboration to optimize patient records.

Responsibilities include concurrent chart review, education for the care team on proper coding guidelines, and guidance to ensure compliance with ICD-10-CM/PCS standards. RN licensure is required with preferred BSN.

Qualifications

• Requires RN licensure and acute care experience.
• Strong understanding of clinical documentation standards.
• Experience with ICD-10-CM and PCS coding guidelines.

Responsibilities

• Facilitate timely and accurate physician documentation in the medical record through concurrent chart review.
• Collaborate with physicians, nursing, and HIM coders to ensure quality coding.
• Educate care teams on proper clinical documentation using approved guidelines.

Skills

Coding guidelines application

Computer data entry

Effective communication

Education

Graduate of an approved nursing program

Bachelor's Degree in Nursing (preferred)

Job description

Facility:West Campus (Chase): 303 E Republic Rd, Springfield, Missouri, United States of America, 65807Department:1669 HIM Documentation ImprovementScheduled Weekly Hours:40Hours:8:00 AM - 4:30 PMWork Shift:Day Shift (United States of America)CoxHealth is a leading healthcare system serving 25 counties across southwest Missouri and northern Arkansas. The organization includes six hospitals, 5 ERs, and over 80 clinics. CoxHealth has earned the following honors for workplace excellence:Named one of Modern Healthcare’s Best Places to work five times.Named one of America’s Greatest Workplaces, Greatest Workplaces in Healthcare (2025, 2026), Greatest Workplaces for Women (2023, 2024), and Greatest Workplaces for Diversity (2024) by Newsweek and Plant-A Insights Group.Acknowledged by Forbes as one of the Best Employers for New Grads.Healthcare Innovation's Top Companies to Work for in Healthcare (2025).BenefitsMedical, Vision, Dental, Retirement with Employer Match and more (20+ hrs/week)For a comprehensive list of benefits, please click here: Benefits | CoxHealthJob Description:• Job Summary This position is responsible for facilitating timely and accurate physician documentation in the medical record through concurrent chart review. Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders is key to the success of this position. This position is also responsible for ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines. Understand and utilization of ICD-10-CM and PCS coding assignment and follow Official Coding Guidelines.• Job Requirements Education Required: Graduate of an approved nursing program Preferred: Bachelor's Degree in Nursing Experience Required: 3 year’s acute care experience, 5 years preferred Preferred: Preferred experience in (ED, ICU, Neuro or Stepdown) Skills Ability to apply coding guidelines when reviewing documentation in the medical record. Ability to perform computer data entry. Ability to work with others and communicate effectively. Licensure/Certification/Registration Required: Registered Nursing License Preferred: CCDS or CDIP Education Required: Graduate of an approved nursing program Preferred: Bachelor's Degree in Nursing Experience Required: 3 year’s acute care experience, 5 years preferred Preferred: Preferred experience in (ED, ICU, Neuro or Stepdown) Skills Ability to apply coding guidelines when reviewing documentation in the medical record. Ability to perform computer data entry. Ability to work with others and communicate effectively. Licensure/Certification/Registration Required: Registered Nursing License Preferred: CCDS or CDIP