RN - Clinical Documentation Specialist

About This Role

This role is for a detail-oriented, analytical RN with strong clinical judgment and a passion for documentation accuracy, who will ensure the accuracy, quality, and completeness of clinical documentation to support exceptional patient care, accurate coding, and appropriate reimbursement.

Responsibilities

• Perform admission and concurrent reviews to identify key diagnoses, comorbidities, and documentation needs
• Collaborate with physicians, coding teams, and clinical staff to clarify and improve documentation
• Conduct follow-up reviews to ensure all clinical information is captured and accurately reflects the patient's severity of illness
• Facilitate documentation clarifications through direct conversations or formal query processes
• Serve as a resource for documentation standards, DRG methodology, coding guidelines, and quality reporting
• Educate physicians and staff on opportunities for improved documentation and compliance
• Ensure documentation supports accurate reporting of HACs, PSIs, and other quality measures
• Participate in quality initiatives, committee work, and departmental collaboration
• Perform other duties as assigned

Requirements

• Four years of recent acute care clinical experience
• Current Louisiana RN licensure
• Strong critical-thinking, communication, and decision-making skills
• Ability to collaborate effectively with physicians, nursing, coding, and interdisciplinary teams
• Exceptional ability to evaluate documentation, identify gaps, and educate clinical staff

Nice to have:

• Utilization Review or coding experience
• BSN

Benefits

• A comprehensive benefits program for you and your family
• Professional development and support
• Various employee perks including generous paid time off, flexible positions, and the Baton Rouge General Fit! program

About the Company

Baton Rouge General is a nationally and locally recognized leader in quality and ranked one of the best healthcare employers in the state. With over 600 licensed beds between three campuses, Baton Rouge General offers the full spectrum of care, from delivering newborns to providing end-of-life support through hospice. With clinics across Baton Rouge and surrounding areas, its physician group provides comprehensive primary and specialty care.