Clinical Documentation Specialist RN

About This Role

Caring for patients and ensuring accurate clinical documentation is the core of this role, which supports complete documentation that reflects the severity of illness, quality of care, and services provided. The Clinical Documentation Improvement (CDI) Nurse Coder reviews medical records, collaborates with providers, and applies clinical expertise and coding knowledge to ensure documentation integrity and compliance with regulatory and organizational standards. This role promotes accurate diagnosis capture, supports quality reporting, and contributes to improved patient outcomes and population health management.

Responsibilities

• Review patient medical records to ensure clinical documentation accurately reflects the patient
• Collaborates with providers and care teams to clarify documentation and ensure accurate capture of diagnoses and conditions in accordance with coding and regulatory guidelines
• Apply clinical knowledge and coding expertise to support accurate risk adjustment documentation, including identification and validation of HCC conditions
• Perform concurrent and retrospective documentation reviews to identify opportunities for documentation improvement and coding accuracy
• Ensure documentation supports accurate CPT, ICD-10, and HCC coding and aligns with regulatory and organizational compliance requirements
• Communicate documentation clarification opportunities to providers through appropriate query processes that align with industry standards
• Educate providers and clinical staff on documentation best practices, coding concepts, and the impact of documentation on quality reporting and risk adjustment
• Support clinical quality initiatives by identifying documentation gaps that impact quality measures and patient outcomes
• Maintain accurate records of reviews, queries, and outcomes within designated tracking systems
• Collaborate with coding, quality, and clinical leadership to improve documentation workflows and reporting accuracy

Requirements

• Associate
• Current, unrestricted Registered Nurse license required
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required. CDI, CRC, CPMA, COC, CEMC
• 3+ years of clinical nursing experience required
• Knowledge of medical terminology, disease processes, and clinical documentation standards
• Knowledge of ICD-10, CPT, and HCC coding methodologies
• Knowledge of risk adjustment principles and quality reporting requirements
• Strong analytical and critical thinking skills
• Excellent written and verbal communication skills
• Ability to review and interpret complex clinical documentation
• Strong organizational and attention-to-detail skills