RN Clinical Documentation Specialist: Coding & Physician Queries

Bestcare; Council Bluffs, Northern (IA, KY); Hybrid; USD 70,000 - 100,000; Full time

Job summary

Nebraska Methodist Health System in Council Bluffs, IA is seeking a Clinical Documentation Specialist to ensure accurate representation of patient diagnoses and procedures through concurrent chart reviews. You will develop physician queries and collaborate with coding staff while educating clinicians across teams.

Required RN licensure with 5 years of clinical nursing experience; BSN preferred. This full-time role follows a daytime schedule and emphasizes teamwork, accuracy, and high-quality

Qualifications

• Graduate of an accredited school of nursing.
• RN license required; BSN preferred.
• Five years of clinical nursing experience in medical-surgical, ICU, case management, or inpatient coding.

Responsibilities

• Performs concurrent review of clinical documentation for selected admissions to ensure accuracy of diagnoses and procedures.
• Assists with physician queries to obtain correct diagnoses and severity of illness per regulatory standards.
• Initiates professional communication with physicians when documentation is unclear or incomplete.
• Tracks responses to documentation queries to identify opportunities for education and improvement.
• Collaborates with coding staff to clarify documentation requirements and conduct regular meetings.
• Delivers education/training to physicians, nurses, and coders in various settings.

Skills

Communication skills

Teaching skills

Critical thinking

Healthcare knowledge

Education

RN license

BSN preferred

Job description

Nebraska Methodist Health System in Council Bluffs, IA is seeking a Clinical Documentation Specialist to ensure accurate representation of patient diagnoses and procedures through concurrent chart reviews. You will develop physician queries and collaborate with coding staff while educating clinicians across teams.

Required RN licensure with 5 years of clinical nursing experience; BSN preferred. This full-time role follows a daytime schedule and emphasizes teamwork, accuracy, and high-quality