Clinical Documentation Specialist - Registered Nurse
Job Summary
The Facility Primrose Place is located at 1115 E Primrose, Springfield, Missouri, United States of America, 65807. CoxHealth is a leading healthcare system serving 25 counties across southwest Missouri and northern Arkansas. It includes six hospitals, five ERs, and over 80 clinics. CoxHealth has earned numerous honors for workplace excellence, including being named one of Modern Healthcare’s Best Places to Work five times.
About the Role
This position facilitates timely and accurate physician documentation in the medical record through concurrent chart review. It involves interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff, including Health Information Management coders.
Responsibilities
- Facilitate timely and accurate physician documentation in the medical record through concurrent chart review.
- Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders.
- Ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines.
- Understand and utilize ICD-10-CM and PCS coding assignment and follow Official Coding Guidelines.
Requirements
- Required: Graduate of an approved nursing program.
- Preferred: Bachelor's Degree in Nursing.
- Required: 3 years’ acute care experience, 5 years preferred.
- PREFERRED: Preferred experience in (ED, ICU, Neuro or Stepdown).
Skills
- Ability to apply coding guidelines when reviewing documentation in the medical record.
- Ability to perform computer data entry.
- Ability to work with others and communicate effectively.
Qualifications
- Required: Registered Nursing License.
- PREFERRED: CCDS or CDIP.
Benefits
Medical, Vision, Dental, Retirement with Employer Match and more (20+ hrs/week). For a comprehensive list of benefits, please click here: Benefits | CoxHealth.
Pay
Scheduled Weekly Hours: 40 Hours Work Shift: Day Shift (United States of America)
Schedule
Scheduled Weekly Hours: 40 Hours Work Shift: Day Shift (United States of America)