Clinical Documentation Specialist: Elevate Chart Accuracy

LCS Lifespan Corporate Services d/b/a Brown University Health; United States; On-site; USD 87,000 - 174,000; Full time

Job summary

Brown University Health is seeking a Clinical Documentation Specialist to audit medical records for accuracy in severity of illness, expected mortality, and care complexity. You will collaborate with physicians, mid-level providers, and coding staff to ensure high specificity and complete documentation.

The role requires RN licensure in Rhode Island, with BSN and 3+ years of clinical experience. Strong communication and education skills are essential as is proficiency with the 3M encoder and

Qualifications

• RN licensure in Rhode Island is required.
• BSN is required; a master’s degree is preferred.
• Physician Assistant or Nurse Practitioner licensure with clinical experience is acceptable.

Responsibilities

• Conduct concurrent auditing of the medical record to assess documentation for severity of illness, ROM and DRG accuracy.
• Identify documentation gaps and clarify with physicians or mid-level providers.
• Develop concise, compliant queries and educate staff on documentation requirements.
• Maintain the CDI database and perform DRG reconciliation to ensure correct principal and secondary diagnoses.

Skills

Nursing licensure

Clinical documentation

Interdisciplinary collaboration

Documentation accuracy

Education

RN licensure in RI

BSN

Master's degree preferred

Physician Assistant or Nurse Practitioner licensure

Job description

Brown University Health is seeking a Clinical Documentation Specialist to audit medical records for accuracy in severity of illness, expected mortality, and care complexity. You will collaborate with physicians, mid-level providers, and coding staff to ensure high specificity and complete documentation.

The role requires RN licensure in Rhode Island, with BSN and 3+ years of clinical experience. Strong communication and education skills are essential as is proficiency with the 3M encoder and