RN Clinical Documentation Specialist

CO310 Jennie Edmundson Memorial Hospital; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

Nebraska Methodist Health System is seeking an experienced RN to perform concurrent review of clinical documentation, ensuring accurate representation of diagnoses and procedures during hospital admissions. This role emphasizes collaboration with physicians and coding staff to improve documentation quality.

Ideal candidates have BSN preferred, RN licensure, and a minimum of five years in medical-surgical nursing, ICU, or related areas.

Qualifications

• Five years of clinical nursing experience or related healthcare roles.
• Excellent verbal and written communication, teaching and collaboration skills.
• Ability to analyze and document patient care accurately and clearly.

Responsibilities

• Perform concurrent review of clinical documentation to ensure accuracy of diagnoses and procedures.
• Assist in physician query development to obtain accurate case mix and coding.
• Communicate with physicians to clarify documentation when incomplete or unclear.
• Monitor documentation quality and provide feedback for process improvements.
• Collaborate with nursing, coding and utilization staff to improve patient records.

Job description

Nebraska Methodist Health System is seeking an experienced RN to perform concurrent review of clinical documentation, ensuring accurate representation of diagnoses and procedures during hospital admissions. This role emphasizes collaboration with physicians and coding staff to improve documentation quality.

Ideal candidates have BSN preferred, RN licensure, and a minimum of five years in medical-surgical nursing, ICU, or related areas.