Clinical Documentation Specialist - Medical Records

St. Peter's Health; Montana; Hybrid; USD 65,000 - 90,000; Full time

Job summary

St. Peter's Health is seeking a Clinical Documentation Specialist to perform concurrent reviews of inpatient records to ensure accurate documentation and coding for quality reporting.

The role emphasizes collaboration with physicians and staff to improve documentation quality and to support coding accuracy. Ideal candidates hold an RN or healthcare-related degree, with 3+ years of clinical experience and 2+ years in clinical documentation.

Qualifications

• RN license with at least 3 years of clinical experience highly preferred.
• 2 years previous clinical documentation experience highly preferred.
• Clinical Documentation Specialist or Inpatient Coding Certification highly preferred.
• Strong attention to detail and a high level of accuracy required.
• Experience may be considered in lieu of certification.

Responsibilities

• Conduct concurrent clinical review of inpatient medical records to ensure accurate and complete documentation of diagnoses and procedures.
• Review clinical information and assign appropriate codes.
• Support quality assurance and reporting efforts.
• Provide education to providers and staff on clinical documentation.
• Develop positive relationships with physicians in a respectful, non-confrontational manner.

Skills

Communication skills

Attention to detail

Relationship building

Education

RN or Healthcare degree

Tools

Clinical Coding knowledge

Job description

Onsite, Remote, or Hybrid

This position provides concurrent clinical review of inpatient medical records to ensure accurate and complete documentation of diagnoses and procedures. Reviews clinical information, assigns appropriate codes, supports quality assurance and reporting efforts, and provides education to providers and staff on clinical documentation. Requires excellent communication skills, strong attention to detail, and the ability to build positive relationships with physicians while providing guidance in a respectful, non-confrontational manner.

Job Description

Onsite, Remote, or Hybrid

This position provides concurrent clinical review of inpatient medical records to ensure accurate and complete documentation of diagnoses and procedures. Reviews clinical information, assigns appropriate codes, supports quality assurance and reporting efforts, and provides education to providers and staff on clinical documentation. Requires excellent communication skills, strong attention to detail, and the ability to build positive relationships with physicians while providing guidance in a respectful, non-confrontational manner.

KNOWLEDGE/EXPERIENCE:

RN license with at least 3 years of clinical experience highly preferred. 2 years previous clinical documentation experience highly preferred. Clinical Documentation Specialist or Inpatient Coding Certification highly preferred. Strong attention to detail and a high level of accuracy required. Experience may be considered in lieu of certification.

EDUCATION:

RN or Healthcare related degree required.

LICENSE/CERTIFICATION/REGISTRY:

RN Licensure Required. Clinical Documentation Specialist certification must be obtained within 2 years.