RN Clinical Documentation Specialist & Educator

Nebraska Methodist Health System; Omaha (NE); On-site; USD 85,000 - 110,000; Full time

Job summary

Nebraska Methodist Health System is seeking a Nursing Documentation Specialist to support concurrent review and ensure accurate clinical reporting for inpatient care. The role emphasizes collaboration with physicians, coders, and care teams to improve documentation quality and patient acuity representation.

Qualifications include RN licensure with BSN preferred and at least five years in medical-surgical, ICU, case management or inpatient coding.

Qualifications

• Graduate of an accredited school of nursing.
• BSN preferred.
• Successful completion of annual mandatory education requirements.

Responsibilities

• Perform concurrent review of clinical documentation for all selected admissions to ensure documentation supports and accurately reflects diseases being treated.
• Assist with development of physician queries to capture correct diagnoses and severity of illness.
• Initiate communication with physicians when documentation is unclear or incomplete.
• Track responses to documentation questions to identify opportunities for physician education.
• Collaborate with coding staff to clarify documentation issues regularly.
• Maintain collaborative relationships with nurses, care coordinators and coding staff.
• Provide education and training to physicians, staff and coders in various settings.
• Partner with physicians and care teams to ensure the medical record reflects patient acuity for quality reporting.

Skills

Communication skills

Teaching skills

Critical thinking

Interprofessional collaboration

Self-starter

Education

RN license

BSN preferred

Job description

Nebraska Methodist Health System is seeking a Nursing Documentation Specialist to support concurrent review and ensure accurate clinical reporting for inpatient care. The role emphasizes collaboration with physicians, coders, and care teams to improve documentation quality and patient acuity representation.

Qualifications include RN licensure with BSN preferred and at least five years in medical-surgical, ICU, case management or inpatient coding.