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Nurse Clinical Documentation Specialist
St. Joseph Hospital (Nashua, NH). Facilitate improvement in the overall quality, completeness, and accuracy of medical records documentation .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement, ensuring accuracy and completeness of medical records while collaborating with healthcare teams. Holds relevant certifications and possesses a strong background in nursing and clinical settings.
Highest-signal resume keywords
Clinical Documentation ImprovementCertified Clinical Documentation Specialist (CCDS)Certified Documentation Integrity Practitioner (CDIP)Bachelor's Degree in NursingThree to Five Years of Experience in Medical/Surgical or Intensive Care
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Records DocumentationDocumentation Guidelines EducationSeverity of Illness AssignmentClinical Documentation ReviewInterdisciplinary Collaboration
Soft Skills
CommunicationInterpersonal SkillsTeam Collaboration
Certifications & Qualifications
Certified Clinical Documentation Specialist (CCDS)Certified Documentation Integrity Practitioner (CDIP)Certified Coding Specialist (CCS)
Industry Keywords
Medical/SurgicalIntensive CareEmergency DepartmentPACUClinical Documentation Integrity
About the role
Key responsibilities & impact- Facilitate improvement in the overall quality, completeness, and accuracy of medical records documentation
- Review records and recommend opportunities for documentation improvement
- Interact extensively with physicians, patient care providers, and the coding team to obtain appropriate clinical documentation
- Ensure clinical documentation reflects the level of service rendered and is complete and accurate
- Educate patient care team members on documentation guidelines
- Apply knowledge and skills to assign accurate severity of illness
Requirements
What you’ll need- Bachelor's degree in Nursing required
- Master's degree preferred
- Three to five years of previous work-related experience in Medical/Surgical, Intensive Care, Emergency Department, or PACU
- Medical school graduate (MD, MBBS) or Registered Nurse (RN)
- Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Integrity Specialists, Certified Documentation Integrity Practitioner (CDIP), or Certified Coding Specialist (CCS) by the American Health Information Management Association within two years or hire
Benefits
Comp & perks- Competitive salary
- Robust benefits with health, dental, Rx and vision plans
- 403b retirement plan options with company match
- Health & Wellness
- Eligible for Federal Student Loan Forgiveness
- PTO and paid holidays
- Tuition reimbursement
- Employee Assistance Program
- Long Term Disability
- Life Insurance Options
- Onsite Day care Program