Clinical Documentation Spec

CoxHealth; United States; On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Benefits package

Job summary

CoxHealth is seeking a Registered Nurse to facilitate timely and accurate physician documentation in the medical record through concurrent chart review. The role requires interdisciplinary collaboration with physicians, nursing staff, and Health Information Management coders.

Ongoing education of the patient care team on proper clinical documentation using ICD-10-CM/PCS guidelines is essential. Education: RN graduate; Bachelor's in Nursing preferred.

Qualifications

• Graduate of an approved nursing program.
• 3 years acute care experience; 5 years preferred.
• RN license required; CCDS or CDIP preferred.

Responsibilities

• Facilitate timely and accurate physician documentation through concurrent chart review.
• Collaborate with physicians, nursing, and HIM coders; educate care team on proper documentation per guidelines.

Skills

Coding guidelines

Data entry

Communication

Education

RN (Licensed)

BSN (preferred)

Job description

Facility: West Campus (Chase): 303 E Republic Rd, Springfield, Missouri, United States of America, 65807 Department: 1669 HIM Documentation Improvement Scheduled Weekly Hours: 40 Hours: 8:00 AM - 4:30 PM Work 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).

Benefits Medical, Vision, Dental, Retirement with Employer Match and more (20+ hrs/week) For a comprehensive list of benefits, please click here: Benefits | CoxHealth.

Job 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

Are you ready to make a meaningful impact in your community? At CoxHealth, we don’t just provide medical services; we've created an atmosphere where innovation, collaboration, values, and excellence come together to transform lives. Whether you desire to work in a clinical or non-clinical capacity, CoxHealth has the perfect position for you! CoxHealth is the region’s employer of choice because we keep our mission, vision, and values in mind with every decision for our employees and our patients.

OUR MISSION

To improve the health of the communities we serve.

OUR VISION

To be the best for those who need us.

OUR VALUES

Safety, compassion, respect, and integrity.

CoxHealth is the area leader in health care and community involvement, with six hospitals, more than 80 clinics, five ERs and more than 14,000 employees throughout southwest Missouri.

We offer a wide range of treatments and services to help with whatever health needs you might have. Whether you're about to become a parent, have an illness or need medical information, we’re here for you. And if your goal is to live a healthy, balanced life with the best tools available, we can help with that, too. We know that your health and the health of your loved ones are some of the most personal, important parts of your life. That's why we keep our Mission, Vision and Values at the center of everything we do, every day.

Thank you for choosing CoxHealth.