Clinical Documentation Improvement Specialist

Nuvance Health

. Facilitate improvement in the quality, completeness and accuracy of medical record documentation .

Posted 11/11/2026full-timeUnited StatesMid-LevelSenior💰 $46 - $85 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation integrity, including the ability to facilitate accurate medical record documentation and collaborate effectively with healthcare teams. Proficient in using 3M for documentation updates and performance tracking while maintaining strong communication with physicians and staff.

Highest-signal resume keywords

Registered Nurse (RN)Clinical Documentation Improvement3M Software ProficiencyInterpersonal Communication SkillsAnalytical Problem Solving

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation GuidelinesAdmission ReviewsDocumentation Opportunities IdentificationPerformance Benchmark TrackingPatient Status Updates

Soft Skills

CollaborationIndependencePrioritizationPositive Relationship BuildingProactive Problem Solving

Tools & Technologies

3M Software

Certifications & Qualifications

Current NY/CT RN Licensure

Industry Keywords

Medical Record DocumentationHealth Information ManagementDRG DeterminationClinical ExpertiseInterdisciplinary Care Team

About the role

Key responsibilities & impact

Facilitate improvement in the quality, completeness and accuracy of medical record documentation
Obtain and promote appropriate clinical documentation through interaction with physicians, nursing staff, patient caregivers, coding and Health Information Management teams
Perform admission reviews for specific patient populations using clinical documentation guidelines
Review physician and clinical documentation, lab results, diagnostic information and treatment plans; capture appropriate information in 3M
Identify documentation opportunities reflecting severity of illness, acuity and resource consumption
Communicate with physicians to clarify documentation opportunities and post physician queries using AHIMA-approved format
Update 3M for changes in patient status, procedures, treatments, physician documentation, lab findings and diagnostic results
Confer with physicians regarding severity of illness, principal diagnosis, comorbid conditions, complications and procedures
Collaborate with coding staff to determine appropriate DRG and required documentation
Provide clinical expertise and references to coding staff
Conduct ongoing education regarding the clinical documentation integrity program and assist with educating new staff and clinical personnel
Track and trend personal performance using 3M data and review performance against established benchmarks
Participate in educational conferences, performance improvement activities and ongoing medical record review
Maintain communication with physicians, interdisciplinary care team members, department leadership and coding staff
Demonstrate regular, reliable and predictable attendance
Perform other duties as required

Requirements

What you’ll need

Registered Nurse (RN) with 5 years recent experience in medical/surgical, critical care, intensive care or emergency room care preferred
Current NY/CT RN Licensure required
Strong interpersonal and communication skills
Ability to form positive, collaborative relationships with physicians and hospital staff
Analytical abilities to assist in obtaining solutions to problems
Ability to work independently and prioritize work
Ability to manage multiple priorities
Computer literacy and willingness to learn job-related computer applications
Ability to problem solve proactively and creatively using sound judgment based on factual information and clinical knowledge
Sedentary/light physical effort; may exert up to 10 lbs. force
Credentials: RN