Registered Nurse, Clinical Documentation Specialist

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Enhance the quality, completeness, and accuracy of medical record documentation.

• Acquire and advocate for appropriate clinical documentation through extensive collaboration with physicians, nursing staff, caregivers, and Health Information Management coding personnel.

• Educate members of the patient care team on documentation standards.

• Conduct admission reviews for designated patient populations in accordance with clinical documentation standards.

• Assist with medical screenings by documenting admission suitability and managing DRG and LOS information.

• Evaluate physician and clinical documentation, laboratory findings, diagnostic data, and treatment strategies.

• Identify opportunities for documentation that reflect the severity of illness, acuity, and resource utilization.

• Engage with physicians and ancillary staff to clarify documentation opportunities.

• Update DRG and Clinical Documentation Management Program worksheets based on patient status, procedures, treatments, and documentation.

• Review medical records every 24–48 hours as necessary.

• Consult with physicians regarding severity of illness, primary diagnoses, comorbid conditions, complications, and procedures.

• Conduct follow-up reviews to ensure that clarified issues are documented in patient records.

• Document, analyze, and report any inappropriate patient care and discharge delays as needed.

• Collaborate with coding personnel to identify the appropriate DRG and required documentation.

• Provide ongoing education in clinical documentation management for new staff, physicians, nursing, and allied health professionals.

• Monitor and analyze program compliance.

• Participate in concurrent performance improvement and medical record review activities.

• Maintain communication with physicians, interdisciplinary care team members, coding staff, and regional management.

⛳️ Requirements

• Registered Nurse (RN) with over 5 years of experience in Med/Surg, Critical Care, ICU, or ED.

• Current RN license in Ohio or Kentucky is required.

• Certification as a Clinical Documentation Specialist (CCDS) is preferred.

• Must achieve a score of 70% or higher on JA Thomas's Clinical Competency Assessment.

• Exceptional verbal and written communication skills.

• Strong interpersonal skills.

• Ability to demonstrate excellent relations with physicians.

🏝️ Benefits

• Competitive compensation.

• Incentives offered.

• Referral bonuses available.

• 403(b) plan with employer contributions (when eligible).

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Prescription drug coverage.

• HAS/FSA options provided.

• Life insurance coverage.

• Access to mental health resources and discounts.

• Paid time off.

• Parental leave options.

• FMLA leave available.

• Short- and long-term disability coverage.

• Backup care services for children and elders.

• Tuition assistance programs.

• Opportunities for professional development.

• Support for continuing education.