RN Clinical Documentation Informaticist

Northern Arizona Healthcare

. Facilitate complete and comprehensive clinical documentation reflecting clinical treatment, diagnosis, severity of illness, and risk of mortality .

Posted 10/22/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation, including the identification of diagnoses, complications, and compliance with MS-DRG assignment. Proficient in collaborating with multidisciplinary teams to enhance documentation processes and ensure adherence to regulatory standards.

Highest-signal resume keywords

Clinical Documentation Specialist ExperienceMS-DRG Assignment KnowledgeRN LicenseCCDS CertificationDocumentation Audits

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical DocumentationCodingUtilization ReviewDocumentation AuditsPrincipal Diagnoses IdentificationSecondary Diagnoses IdentificationComplications/Comorbidities IdentificationData TrackingRegulatory CompliancePatient Review

Soft Skills

CommunicationCollaborationEducationLeadershipProblem-Solving

Tools & Technologies

Basic Software ProgramsTracking Database

Certifications & Qualifications

RN LicenseCCDS Certification

Industry Keywords

Clinical TreatmentSeverity of IllnessRisk of MortalityComorbiditiesCase MixHIM CodersArizona State Board of Nursing LawsSafety TrainingFederal RegulationsState Regulations

About the role

Key responsibilities & impact

Facilitate complete and comprehensive clinical documentation reflecting clinical treatment, diagnosis, severity of illness, and risk of mortality
Work with a multidisciplinary team to improve clinical documentation
Apply knowledge of complications, comorbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, and procedures' impact on DRG
Review assigned cases and perform documentation audits for consistency and compliance with standards
Communicate with physicians to clarify information, obtain documentation, present opportunities, and educate on appropriate MS-DRG assignment
Confer with HIM coders to ensure appropriate MS-DRG assignment and complete supporting documentation
Confer with the Physician Advisor as needed
Conduct concurrent and retrospective reviews of assigned patients
Identify and record principal diagnoses, secondary diagnoses, complications/comorbidities, and procedures
Identify opportunities to improve documentation processes
Maintain accurate tracking database data, identify trends and issues, and develop action plans
Report safety-related incidents, attend safety training, and monitor the work environment for safety issues
Stay current with applicable state and federal regulations and company policies

Requirements

What you’ll need

Associate's degree with RN, RHIA/RHIT, or bachelor's degree with experience/certification in Coding/CDI — required
BSN preferred
CCDS required after 2 years of experience
Current RN license required; license does not have to be Arizona
3–5 years of clinical documentation specialist, coding, or utilization review experience preferred
Supervisory, education, or leadership experience preferred
Understanding of computers and competence using computers and basic software programs
Ability to comply with Arizona State Board of Nursing Laws and Regulations
Ability to maintain current certifications and/or licenses
Ability to complete mandatory modules and required job-specific training within specified time frames

Benefits

Comp & perks

Regular full-time employment (40 hours)
Remote work available in eligible states
Company-provided mandatory and job-specific training