What are the responsibilities and job description for the Documentation Specialist position at RADHealth?
Description:
Job Title: RN – Clinical Documentation Specialist
Assignment: 13-Week Contract
Shift: Day Shift, 5x8-Hour (08:00 – 16:30)
Position Summary
The RN Clinical Documentation Specialist (CDS) is responsible for improving the overall quality and completeness of clinical documentation within the inpatient acute care setting. This role ensures accurate reflection of patient severity, risk of mortality, and quality outcomes through detailed medical record review, provider collaboration, and compliance with regulatory standards.
Pay Package:-
Gross Pay: $ 2695.02 / Week
W2 / Taxable Pay: $ 960.00 / Week
Per Diem: $ 1735.02 / Week
Key Responsibilities
- Review inpatient medical records to ensure accurate, complete, and compliant clinical documentation
- Conduct post-discharge record reviews, including mortality chart reviews
- Initiate and manage clinical documentation queries to clarify diagnoses, procedures, and clinical indicators
- Communicate effectively with physicians and interdisciplinary teams to improve documentation specificity
- Perform audits and ensure compliance with regulatory and organizational standards
- Ensure timely intake, investigation, documentation, and response to CMS-defined patient grievances
- Provide clinical oversight of event reporting, including triage and escalation
- Facilitate and monitor Root Cause Analyses (RCAs) and Failure Mode and Effects Analyses (FMEAs), including corrective action plans
- Support regulatory inquiries, complaint investigations, and survey readiness activities
- Respond to patient complaints and grievances across departments as needed
- Review event reports and ensure appropriate follow-up and documentation
- Maintain continuity of patient safety and risk management functions
Required Qualifications
- Active RN license
- Minimum 2 years of clinical experience (Required – Hard Stop)
- Inpatient Acute Care experience required
- Experience with Epic charting system (Required)
- BLS Certification (Required)
- Strong knowledge of clinical documentation standards and regulatory compliance
- Ability to work independently and collaborate with multidisciplinary teams
Preferred Qualifications
- Previous Charge Nurse experience
- Experience in Critical Care or Emergency Department (ED)
- Experience with clinical documentation improvement (CDI) processes
- Strong query writing and resolution skills
Salary : $960 - $2,695