Clinical Documentation Specialist - Registered Nurse
Listed on 2026-06-05
-
Nursing
RN Nurse, Healthcare Nursing
Position Summary
Facility:
Primrose Place, 1115 E Primrose, Springfield, Missouri 65807.
Department: 1669 HIM Documentation Improvement.
Hours:
40 per week.
Schedule:
8:00 AM - 4:30 PM. Shift: Day Shift.
This position is responsible for facilitating timely and accurate physician documentation in the medical record through concurrent chart review. Interdisciplinary communication and collaboration with physicians, nursing, and ancillary staff including Health Information Management coders is key to the success of this position. The role also involves ongoing education of the patient care team regarding proper clinical documentation using approved guidelines and utilization of ICD-10-CM and PCS coding assignment following Official Coding Guidelines.
EducationRequired:
Graduate of an approved nursing program.
Preferred:
Bachelor’s Degree in Nursing.
Required:
3 years acute care experience (5 years preferred).
Preferred:
Experience in ED, ICU, Neuro, or Stepdown.
- Ability to apply coding guidelines when reviewing documentation in the medical record.
- Proficiency in computer data entry.
- Ability to work with others and communicate effectively.
Required:
Registered Nursing License.
Preferred: CCDS or CDIP.
BenefitsMedical, Vision, Dental, Retirement with Employer Match and more (20+ hrs/week).
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