RN Clinical Documentation Specialist- Medical Records

Huntsville Hospital; Huntsville (AL); On-site; USD 60,000 - 90,000; Full time

Job summary

An established healthcare provider is seeking a dedicated Clinical Documentation Specialist to enhance the quality of medical record documentation. This role involves collaborating with physicians and nursing staff to ensure accurate clinical data and metrics for reimbursement. The ideal candidate will have a strong nursing background, preferably with CDI experience, and will be committed to ongoing education in clinical documentation. With a focus on patient-centered care, this position offers the chance to work in a leading hospital recognized for its excellence in various medical fields. Join a team that values skill development and offers competitive benefits.

Benefits

Health and wellness programs

Childcare

Onsite pharmacy

Free health clinic

Tuition assistance

Student loan reimbursement

Employee discounts

Qualifications

• Graduate of an accredited school of nursing required.
• Current Alabama Nursing License is mandatory.

Responsibilities

• Facilitate improvement in medical record documentation quality.
• Ensure accurate clinical data and quality metrics for services.

Skills

Medical/Surgical Nursing Experience

Critical Care Nursing Experience

Word proficiency

Excel proficiency

Strong time management skills

Self-motivated

Critical thinking skills

Education

Graduate of an accredited school of nursing

Associate's Degree in Nursing

BSN

MSN

Job description

Overview

Responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. Obtain appropriate clinical documentation through interaction with physicians, nursing staff, patient caregivers, and coders. Ensure that patient-centered clinical data, quality metrics, and reimbursement are accurately received for services rendered. Confirm that clinical information used in profiling and reporting outcomes is complete and accurate. Maintain ongoing education relevant to CDI/ACDIS/AHIMA and the Coding Clinic.

Qualifications

Education required: Graduate of an accredited school of nursing.

Education preferred: Associate's Degree in Nursing, BSN, or MSN.

License, Certification and/or Registration: Current Alabama Nursing License. CCDS Certification preferred or will be obtained within 2-3 years.

Experience: Prefer at least 3-7 years of experience in an acute care hospital setting. Prefer at least 1 year of CDI experience; if no prior CDI experience, applicant will be educated to current standards.

Additional Skills/Abilities:

• Medical/Surgical Nursing Experience
• Critical Care Nursing Experience
• Word and Excel proficiency preferred
• Strong time management skills
• Self-motivated
• Critical thinking skills

About Us

Highlights of our hospitals

Huntsville Hospital was recently named Best Regional Hospital and #2 in Alabama by U.S. News & World Report. With 971 beds, a specialized Orthopedic & Spine Tower, a Level III Regional Neonatal ICU, and the largest Emergency Department and Level 1 Trauma Center in the state, including our Red Shirt Trauma Program, there are many opportunities to apply your skills. We are a certified Primary Stroke Center and ranked among the Top 100 Hospitals in the nation with excellent heart programs. Facilities include six cath labs and four EP labs, along with multiple medical and step-down units, supporting continual skill development. We offer a training center for continuing education, Shared Governance, a Clinical Ladder, The Daisy Award, and Nurse Residency Program for new grads. Our benefits include health and wellness programs, childcare, onsite pharmacy, free health clinic, tuition assistance, and more. We value diversity and are an equal opportunity employer, partnering with the U.S. Army’s PaYS program. Ask us about incentives and additional opportunities.

Huntsville Hospital Benefits:

We offer competitive benefits including medical, dental, vision, life insurance, flexible spending, disability coverage, multiple retirement options with 401K match, nurse residency, tuition assistance, student loan reimbursement, onsite training, employee discounts, and more.

Learn more about Huntsville Hospital Health System:

• Careers: https://careers.hhsys.org/careers-home
• Benefits: https://careers.hhsys.org/us/en/benefits
• Education & Professional Development: https://www.huntsvillehospital.org/education
• Life In Huntsville: https://www.huntsvillehospital.org/about-huntsville-al