Facilitate improvement in the overall quality and completeness of provider-based clinical documentation
Assist treating providers to ensure documentation accurately reflects diagnostic related group (DRG), severity of illness (SOI), risk of mortality (ROM), risk adjustment, and complexity of patient care rendered
Conduct accurate and timely concurrent record reviews
Ensure data integrity of clinical documentation database
Educate customers through presentations and/or reports for clinicians and facility management

Registered Nurse (RN) license in state of residence
Strong knowledge of clinical care obtained through completion of a bachelor’s degree in nursing
Two years of acute clinical care experience
Ability to interface with multiple software applications
Demonstrated critical thinking skills
Problem-solving abilities
Must demonstrate ability to work effectively in an interdisciplinary team format

RN Clinical Documentation Specialist

Key skills