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Clinical Documentation Specialist, RN
St. Tammany Health System. Facilitate improved integrity of medical record documentation through interaction with healthcare providers .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement, including knowledge of ICD-10 coding principles, Risk Adjustment Coding, and medical necessity standards. Proficient in collaborating with healthcare providers to enhance documentation integrity and educate teams on coding requirements.
Highest-signal resume keywords
ICD-10 Coding PrinciplesRisk Adjustment CodingClinical Documentation ImprovementRegistered Nurse License3M Software Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation ReviewMedical Necessity StandardsDRG PrinciplesHCC Documentation RequirementsAmbulatory Care ExperienceCritical ThinkingOrganizational SkillsPlanning Skills
Soft Skills
Excellent Communication SkillsInterpersonal SkillsSelf-MotivatedAbility to Work Independently
Tools & Technologies
Microsoft Office3M SoftwareEncoder
Certifications & Qualifications
Registered Nurse LicenseCertified Clinical Documentation Specialist (CCDS)
Industry Keywords
Healthcare ProvidersPatient ComplexitySeverity of IllnessMortality RiskOutpatient Setting
About the role
Key responsibilities & impact- Facilitate improved integrity of medical record documentation through interaction with healthcare providers
- Support appropriate representation of severity of illness, risk of mortality, acuity, and complexity of care
- Perform pre-visit and retrospective reviews of ambulatory clinical documentation
- Ensure accurate depiction of patient complexity to support the facility’s Risk Adjustment strategy
- Apply clinical and nursing knowledge, CMS coding guidelines, DRG principles, HCC documentation requirements, ICD-10-CM accuracy and specificity, and medical necessity standards
- Collaborate with physicians and advanced practice providers
- Communicate documentation opportunities
- Educate patient care team members regarding documentation guidelines, coding requirements, and service-line-specific requirements
Requirements
What you’ll need- Graduate of an accredited School of Nursing
- Current Louisiana Registered Nurse License required
- Five (5) years of clinical experience in an acute or ambulatory care setting
- Knowledge of ICD-10 coding principles and guidelines and Risk Adjustment Coding
- Proficiency in Microsoft Office applications (PowerPoint, Excel, Word)
- Experience with 3M software and Encoder
- Excellent written and verbal communication skills
- Critical thinking and interpersonal skills
- Knowledge of complex disease processes with broad clinical experience in an outpatient setting
- Ability to work independently with minimal supervision and be self-motivated
- Proficient organizational and planning skills
- Good physical health
- Ability to stand, sit, or walk for long periods
- Ability to lift at least 20 pounds
- Ability to work with a moderate level of noise
- Preferred: Bachelor of Science degree in Nursing
- Preferred: Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing, and auditing
- Preferred: Current Certified Clinical Documentation Specialist (CCDS) through ACDIS
Benefits
Comp & perks- Fully remote work arrangement
- Attractive compensation package
- Full-time schedule, 40 hours per week
- Monday–Friday work schedule
- Employee assistance with mission, vision, and values expectations
- Equal employment opportunity