Clinical Documentation RN Specialist (Full Time, Days)

Job Summary

Responsible for leading comprehensive clinical documentation audits to ensure accuracy, compliance, and alignment with regulatory and organizational standards for Emergency Services. Primary responsibilities include conducting focused and routine audits across key clinical domains, including sepsis, restraints, triage, sedation, discharge process, weight discrepancies, and assessment/reassessment compliance. Through detailed chart reviews, identifies gaps and documentation discrepancies that impact both clinical quality outcomes and appropriate charge capture. Actively works to mitigate missed revenue opportunities by ensuring accurate facility charge codes within the appropriate timeframe. Maintains clinical competency by working a minimum of one bedside shift per week to ensure strong alignment with frontline workflows and real-time documentation practices. Promotes a culture of accountability, continuous improvement and regulatory readiness by supporting audit readiness efforts and assisting leadership in monitoring performance against key quality and compliance metrics. Acts as a resource to staff and leadership, fostering strong professional relationships and consistently demonstrating excellence in service.

Job Specific Duties

• Educates and provides consultation services to clinical staff in reference to documentation and charge capture process, procedures, concerns and issues.
• Assesses the accuracy of medical records documentation to ensure it supports the diagnoses, conditions, problems or other reasons for the visit.
• Identifies documentation trends and deficiencies, and develops and disseminates education for nursing staff improvement.
• Develops PowerPoint presentations and presents material at staff meetings.
• Instructs and coaches employees with charge entry and documenting audits.
• Posts accurate patient specific charges to the system within 3 business days of service in order to ensure timely billing to patients and third party insurers.
• Performs daily charge reconciliation and procedure appropriate for respective department.
• Acts as a resource to NCHS leaders regarding documentation and department charge processes. Remains current with healthcare trends.
• Updates standard operating procedure for facility charges in the department.
• Reviews and maintains quality measures for clinical documentation and charge capture.
• Coordinates trainings for charge process and accuracy.
• Communicates to department leadership and Revenue Integrity compliance of documentation review and findings.
• Serves as a liaison between department, nursing and physician leadership, Revenue Integrity, and Health Information Management.
• Meets or exceeds unit standards in achieving hospital-wide CEI/SEI; completes documentation in a timely manner, & is accountable to regulatory requirements of the DNV & other accrediting agencies.
• Performs all RN Emergency Services duties, including but not limited to, completing a comprehensive multi-system assessment that includes Cardiac, Respiratory and Neurological. Develops a plan of care and conducts reassessments. Provides care such as starting/monitoring IV’s, specimen collection, POC testing, medication administration, and assists medical team with other procedures and promotes an “error-free” working environment by consistently providing high-quality safe care as prompted including sedation as required per policy. Ensures accurate completion of triage documentation including vital signs and patient history as per department and hospital policies and procedures.

Minimum Job Requirements

• Bachelor's Degree BSN
• RN Licensure within the State of Florida or Multi-State Enhanced Nursing License Compact (eNLC) – maintain active and in good standing throughout employment
• American Heart Association BLS - maintain active and in good standing throughout employment
• American Heart Association PALS required within 2 years of hire - maintain active and in good standing throughout employment
• Crisis Prevention Institute (CPI) required within 1 year - maintain active and in good standing throughout employment
• 3-5 years of clinical RN experience
• 1-3 years of experience in clinical documentation review, charge capture and revenue integrity.

Knowledge, Skills, and Abilities

• Nursing experience in a pediatric healthcare setting is strongly preferred.
  
  • Possesses proficiency in computers and Electronic Medical Record (EMR).
  
  • Effective verbal and written communication skills.
  
  • Ability to positively influence, hold self and others accountable.
  
  • Able to work effectively in collaborative environment.
  
  • Demonstrate problem solving skills.
  
  • Ability to maintain confidentiality of sensitive information.
  
  • Outstanding analytical and organizational skills with attention to detail.
  
  • Able to analyze and interpret data and utilize the information to make judgments regarding patient care.