Clinical Documentation Specialist

Nebraska Methodist Health System; Council Bluffs (IA); On-site; USD 60,000 - 80,000; Full time

Job summary

Nebraska Methodist Health System is seeking a skilled Registered Nurse for concurrent review of clinical documentation. This role involves assisting with physician queries, ensuring accurate documentation, and education of medical staff.

Ideal candidates will have five years of clinical experience in nursing or related fields, along with strong communication and critical thinking skills. The role offers a chance to work in a collaborative environment at Methodist Jennie Edmundson Hospital in Council Bluffs, IA.

Qualifications

• Five years clinical experience in medical-surgical nursing, ICU, case management, or inpatient clinical coding.
• Current valid Registered Nurse (RN) license or temporary permit.
• Successful completion of annual mandatory education requirements.

Responsibilities

• Perform concurrent review of clinical documentation for selected admissions.
• Conduct 25–30 reviews daily.
• Assist with development of physician queries.

Skills

Excellent communication skills

Critical thinking

Teamwork and collaboration

Teaching skills

Education

Graduate of an accredited school of nursing

Bachelor of Science in Nursing (BSN)

Job description

Job Summary

Location: Methodist Jennie Edmundson Hospital, 933 E. Pierce St., Council Bluffs, IA
Work Schedule: Mon – Fri, daytime business hours.

Responsible for concurrent review of clinical documentation for selected admissions to ensure an accurate representation of the clinical condition of the patient through complete and accurate reporting of diagnoses and procedures.

Responsibilities

• Perform concurrent review of clinical documentation for selected admissions, ensuring documentation supports and accurately reflects all disease processes being treated.
• Conduct 25–30 reviews daily.
• Assist with development of physician queries to comply with the query process, ensuring correct clinical diagnoses and capture of severity of illness.
• Demonstrate knowledge of appropriate, worded queries that meet regulatory, legal, and ethical standards.
• Initiate assertive professional communication with physicians when documentation is unclear, incomplete, or lacks necessary completeness to assign ICD‑10 codes by completing query forms or face‑to‑face communication.
• Track responses to documentation queries, monitoring compliance and identifying opportunities for physician feedback and education.
• Maintain collaborative relationships with coding staff, staff nurses, care coordinators, utilization review staff and other hospital personnel.
• Provide education and training to physicians, physician office staff, nurses and coders, including one‑on‑one sessions, group presentations and quick sessions during rounds.
• Work with physicians, care coordinators, utilization management, staff nurses and Coding Specialists to ensure the medical record accurately reflects patient acuity for quality reporting and case mix index.

Job Requirements

• Education: Graduate of an accredited school of nursing required. Bachelor of Science in Nursing (BSN) preferred. Successful completion of annual mandatory education requirements.
• Experience: Five years clinical experience in medical‑surgical nursing and/or ICU, or case management, or inpatient clinical coding, or healthcare revenue cycle.
• License/Certification: Current valid Registered Nurse (RN) license, valid compact multistate license, or a temporary permit while awaiting licensure required.
• Skills/Knowledge/Abilities: Excellent communication skills; verbal, written and strong teaching skills; critical thinking; knowledge of healthcare delivery system; develops collaborative relationships with physicians; self‑starter able to deal with resistance and complex situations; fosters teamwork and trust; functions as an educator and enabler to physicians, must be objective and logical.

Physical Requirements

• Weight Demands: Light work – up to 20 pounds of force.
• Physical Activity:
  • Not necessary: climbing, crawling, kneeling.
  • Occasionally performed (1–33%): balancing, carrying, crouching, distinguishing colors, grasping, lifting, pulling/pushing, standing, stooping/bending, twisting, walking.
  • Frequently performed (34–66%): keyboarding/typing, reaching, repetitive motions, sitting, speaking/talking.
  • Constantly performed (67–100%): hearing, seeing/visual.

Job Hazards

• Not Related: Chemical agents (toxic, corrosive, flammable, latex); physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps); equipment/machinery/tools; explosives; electrical shock/static; radiation (alpha, beta, gamma, non‑ionizing); mechanical moving parts/vibrations.
• Rare (1–33%): Biological agents (airborne and bloodborne viruses) (Jobs with patient contact).

EEO Statement

Nebraska Methodist Health System is an affirmative action/equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation, gender identity, or any other classification protected by Federal, state or local law.