Clinical Documentation Specialist (RN)

Description

MaineHealth Corporate

Nursing
Req #: 26405

Per Diem/Days

This individual is responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. S/he will obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and coordinate with Health Information Management coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients. S/he will also assure that the clinical information utilized in profiling and reporting outcomes is complete and accurate. S/he will provide education for all members of the patient care team on documentation guidelines.

***Recent acute care experience required, with a minimum of 5 years acute care nursing experience***

Summary:

The Clinical Documentation Specialist role is responsible for facilitating the improvement in the overall quality and completeness of medical record documentation, obtaining appropriate clinical documentation through extensive interaction with providers nursing staff, and other caregivers and coordinating with coding staff to ensure reimbursement is received for patient services rendered.

Required Minimum Knowledge, Skills, and Abilities (KSAs)

• Education: Graduate of an accredited School or Nursing, BSN preferred.
• License/Certifications: Current applicable state(s) license as a Registered Nurse required.
• Experience: Five years of acute care nursing experience required.
• Additional Skills/Requirements Required: N/A
• Additional Skills/Requirements Preferred: N/A

Additional Information

With a career at any of the MaineHealth locations across Maine and New Hampshire, you'll be working with health care professionals that truly value the people around them - both within the walls of the organization and the communities that surround it.

We offer benefits that support an individual's needs for today and flexibility to plan for tomorrow - programs such as paid parental leave, a flexible work policy, student loan assistance, training and education, along with well-being resources for you and your family.

MaineHealth remains focused on investing in our care team and developing an inclusive environment where you can thrive and feel supported to realize your full potential. If you're looking to build a career in a place where people help one another deliver best-in-class care, apply today.

If you have questions about this role, please contact Amanda L. Oliveira at amanda.oliveira@mainehealth.org