RN specializing in clinical documentation integrity for pediatric patients at Connecticut Children's. Collaborating with healthcare providers to enhance documentation standards and accuracy.
About the role
- Clinical Documentation Specialist ensuring accuracy and completeness of clinical documentation for healthcare providers. Collaborating with medical staff to meet compliance and regulatory standards.
Responsibilities
- Review clinical notes, medical charts, and coding documentation for accuracy and completeness
- Collaborate with physicians, nurses, and coders to clarify or improve clinical documentation
- Identify gaps or inconsistencies in patient records and ensure compliance with U.S. regulatory standards
- Maintain patient confidentiality and follow HIPAA and company-specific privacy guidelines
- Generate reports and documentation summaries as required
- Participate in training and quality improvement initiatives
Requirements
- Must hold at least a bachelor’s degree
- Minimum 5+ years of clinical experience in U.S. healthcare, with pharmacy experience required
- Proficient in Excel, QuickBooks, MS Office; familiarity with NexGen EHR (preferred)
- Clinical documentation, coding knowledge (ICD-10, CPT), and compliance expertise
- Strong communication and interpersonal skills
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