Clinical Documentation Specialist (RN) - Home Care

About the role

The Clinical Documentation Specialist (RN) supports the Agency's efforts to ensure accurate, complete, and compliant clinical documentation in alignment with regulatory standards and payer requirements. This role performs HIM, utilization review (UR), and clinical documentation review functions, while regularly collaborating with clinical staff to ensure documentation accurately reflects patient condition, services provided, and medical necessity.

Responsibilities

• Performs HIM, utilization review (UR), and clinical documentation review functions
• Collaborates with clinical staff to ensure documentation accurately reflects patient condition, services provided, and medical necessity
• Contributes to the Agency's QAPI program through audits, data tracking, and identification of documentation improvement opportunities
• Primarily office-based role with occasional remote work options
• May require spending time in patient care settings in SJ Housing and patient homes in the community

Requirements

• Minimum Education and/or Training: Bachelor's degree in a relevant field (e.g., nursing). Master's degree preferred.
• Minimum Experience: 3+ years of relevant experience in a healthcare setting with familiarity with standards of care, medical record documentation, and exposure to medical terminology. 3+ years of nursing experience preferred. 2+ years of Home Health experience preferred.
• Experience with EMRs in a previous setting preferred.
• At least 6 months of experience with Utilization Review responsibilities, QAPI program management, and/or Health Information Management tasks preferred.
• Pediatric experience preferred.
• Experience with quality improvement, utilization management, risk reduction/safety management, and related issues preferred.
• Experience working with accreditation and regulatory standards and their application to patient care preferred.

Qualifications

• Licensure, Registration and/or Certification Required by Law: (LC: RN-TN) Must possess a current Tennessee State Board of Nursing license if primary residence is Tennessee or a non-Nurse Licensure Compact state. (LC: RN-ARK or RN-MISS) Must possess a current State Board of Nursing license in the state of primary residence if the state is a Nurse Licensure Compact state.
• Licensure, Registration and/or Certification Required by SJCRH Only: Certified Professional in Healthcare Quality (CPHQ) or Certified Clinical Documentation Specialist (CCDS) certification must be obtained within 2 years of employment.

Skills

• Familiarity with standards of care, medical record documentation, and exposure to medical terminology
• Experience with EMRs in a previous setting
• Utilization Review responsibilities, QAPI program management, and/or Health Information Management tasks
• Quality improvement, utilization management, risk reduction/safety management, and related issues
• Experience working with accreditation and regulatory standards and their application to patient care

Benefits

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Pay

In recognition of certain U.S. state and municipal pay transparency laws, St. Jude is including a reasonable estimate of the compensation range for this role. This is an estimate offered in good faith and a specific salary offer takes into account factors that are considered in making compensation decisions including but not limited to skill sets, experience and training, licensure and certifications, and other business and organizational needs. It is not typical for an individual to be hired at or near the top of the salary range and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current salary range is $70,720 - $126,880 per year for the role of Clinical Documentation Specialist (RN) - Home Care.

Schedule

Primarily office-based role with occasional remote work options. May require spending time in patient care settings in SJ Housing and patient homes in the community. Occasional weekend/holiday responsibilities may be needed.