ChristianaCare
RN - Clinical Documentation Specialist - Day Shift
ChristianaCare, Newark, Delaware, United States, 19711
RN – Clinical Documentation Specialist – Day Shift
Join us to apply for the
RN – Clinical Documentation Specialist – Day Shift
role at
ChristianaCare . This range is provided by ChristianaCare. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.
Base Pay Range $85,862.40/yr – $137,384.00/yr
Job Details RN Senior Clinical Documentation Specialist – Day Shift (Hours: M‑F 8 hrs). Hybrid position with onsite requirements. No weekends or holidays. Newark, DE.
Primary Function Responsible to ensure that health care services are administered with quality, cost‑efficiency, and within compliance, and to improve the overall quality and documentation within the inpatient medical record.
Scope, Purpose, and Frequency of Contacts Daily contact with Clinical Documentation Manager, HIMS/coding staff, Physician Advisor, and intradepartmental personnel. Frequent contact with physicians, physician office staff, clinical and ancillary departmental staff.
Principal Duties & Responsibilities
Concurrent review of inpatient medical records throughout hospitalization; analyze clinical status, current treatment, past medical history, and identify gaps in physician documentation.
Communicate with physicians or other providers to validate diagnoses, clinical indicators, and appropriate prompts for documentation.
Demonstrate knowledge of HIMS standards of coding and apply to ongoing evaluation of medical record documentation.
Educate physicians and key healthcare providers on best practice clinical documentation and the need for accurate, complete documentation.
Review and clarify clinical issues in the health record to support accurate DRG assignment, severity of illness, and risk of mortality.
Monitor patient progress; consult with primary physician or designee and other team members at agreed‑upon intervals or more frequently as needed.
Participate in performance improvement activities regarding documentation improvement.
Maintain confidentiality of patient, member, and staff information.
Attend coding/financial/CDI educational programs and regulatory educational programs to maintain proficiency.
Review PSI encounters for completeness and accuracy.
Review outcomes with Physician Advisors and Medical Directors as needed.
Attend daily huddles with HIMS to address any clinical concerns.
Compute a working DRG to identify anticipated length of stay; share with the care team for LOS goals.
Use Vizient data to identify documentation opportunities and targeted physician education.
Perform assigned work safely, adhering to established departmental safety rules and practices; report unsafe activities, conditions, hazards, or violations to manager promptly.
Perform other related duties as required.
Education and Experience Requirements
DE RN licensed or Compact State.
Minimum 3 years recent experience as a Registered Nurse in acute care, adult care setting preferred.
RN experience in Cardiac, Critical Care, Med‑Surg, and Oncology highly desirable.
Clinical Documentation, Case Management, Performance Improvement, or Inpatient Coding experience highly desirable.
Certified Clinical Documentation Specialist (CCDS) required within one year after eligibility.
Knowledge, Skill, and Ability
Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes.
Knowledge of nursing principles, practices, and processes.
Knowledge of ICD‑10, UHDDS, and general coding principles; CMS, JCAHO, and external regulatory and quality requirements.
Knowledge and ability to comply with HIPAA.
Knowledge of performance improvement principles.
Ability to work efficiently independently.
Ability to collaborate with clinicians and administrative staff.
Ability to utilize computer applications on various platforms.
Ability to manage multiple projects with shifting priorities.
Ability to plan and organize work assignments.
Physical Demands Prolonged daily review of charts on computer screen.
Working Conditions Nursing Unit Environment – no patient contact. Normal office environment. Frequent deadline situations.
Benefits ChristianaCare offers a competitive suite of employee benefits to maximize the wellness of you and your family, including health insurance, paid time off, retirement, and an employee assistance program.
Equal Opportunity Christiana Care Health System is an equal‑opportunity employer and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.
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RN – Clinical Documentation Specialist – Day Shift
role at
ChristianaCare . This range is provided by ChristianaCare. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.
Base Pay Range $85,862.40/yr – $137,384.00/yr
Job Details RN Senior Clinical Documentation Specialist – Day Shift (Hours: M‑F 8 hrs). Hybrid position with onsite requirements. No weekends or holidays. Newark, DE.
Primary Function Responsible to ensure that health care services are administered with quality, cost‑efficiency, and within compliance, and to improve the overall quality and documentation within the inpatient medical record.
Scope, Purpose, and Frequency of Contacts Daily contact with Clinical Documentation Manager, HIMS/coding staff, Physician Advisor, and intradepartmental personnel. Frequent contact with physicians, physician office staff, clinical and ancillary departmental staff.
Principal Duties & Responsibilities
Concurrent review of inpatient medical records throughout hospitalization; analyze clinical status, current treatment, past medical history, and identify gaps in physician documentation.
Communicate with physicians or other providers to validate diagnoses, clinical indicators, and appropriate prompts for documentation.
Demonstrate knowledge of HIMS standards of coding and apply to ongoing evaluation of medical record documentation.
Educate physicians and key healthcare providers on best practice clinical documentation and the need for accurate, complete documentation.
Review and clarify clinical issues in the health record to support accurate DRG assignment, severity of illness, and risk of mortality.
Monitor patient progress; consult with primary physician or designee and other team members at agreed‑upon intervals or more frequently as needed.
Participate in performance improvement activities regarding documentation improvement.
Maintain confidentiality of patient, member, and staff information.
Attend coding/financial/CDI educational programs and regulatory educational programs to maintain proficiency.
Review PSI encounters for completeness and accuracy.
Review outcomes with Physician Advisors and Medical Directors as needed.
Attend daily huddles with HIMS to address any clinical concerns.
Compute a working DRG to identify anticipated length of stay; share with the care team for LOS goals.
Use Vizient data to identify documentation opportunities and targeted physician education.
Perform assigned work safely, adhering to established departmental safety rules and practices; report unsafe activities, conditions, hazards, or violations to manager promptly.
Perform other related duties as required.
Education and Experience Requirements
DE RN licensed or Compact State.
Minimum 3 years recent experience as a Registered Nurse in acute care, adult care setting preferred.
RN experience in Cardiac, Critical Care, Med‑Surg, and Oncology highly desirable.
Clinical Documentation, Case Management, Performance Improvement, or Inpatient Coding experience highly desirable.
Certified Clinical Documentation Specialist (CCDS) required within one year after eligibility.
Knowledge, Skill, and Ability
Extensive knowledge of medical terminology, anatomy, physiology, pharmacology, and disease processes.
Knowledge of nursing principles, practices, and processes.
Knowledge of ICD‑10, UHDDS, and general coding principles; CMS, JCAHO, and external regulatory and quality requirements.
Knowledge and ability to comply with HIPAA.
Knowledge of performance improvement principles.
Ability to work efficiently independently.
Ability to collaborate with clinicians and administrative staff.
Ability to utilize computer applications on various platforms.
Ability to manage multiple projects with shifting priorities.
Ability to plan and organize work assignments.
Physical Demands Prolonged daily review of charts on computer screen.
Working Conditions Nursing Unit Environment – no patient contact. Normal office environment. Frequent deadline situations.
Benefits ChristianaCare offers a competitive suite of employee benefits to maximize the wellness of you and your family, including health insurance, paid time off, retirement, and an employee assistance program.
Equal Opportunity Christiana Care Health System is an equal‑opportunity employer and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.
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