Clinical Documentation Spec

Facility:

West Campus (Chase): 303 E Republic Rd Springfield Missouri United States of America 65807

Department:

1669 HIM Documentation Improvement

Scheduled Weekly Hours:

40

Hours:

8:00 AM - 4:30 PM

Work Shift:

Day Shift (United States of America)

CoxHealth is a leading healthcare system serving 25 counties across southwest Missouri and northern Arkansas. The organization includes six hospitals 5 ERs and over 80 clinics. CoxHealth has earned the following honors for workplace excellence:

• Named one of Modern Healthcares Best Places to work five times.

• Named one of Americas Greatest Workplaces Greatest Workplaces in Healthcare () Greatest Workplaces for Women () and Greatest Workplaces for Diversity (2024) by Newsweek and Plant-A Insights Group.

• Acknowledged by Forbes as one of the Best Employers for New Grads.

• Healthcare InnovationsTop Companies to Work for in Healthcare (2025).

Benefits

• Medical Vision Dental Retirement with Employer Match and more (20 hrs/week)

• For a comprehensive list of benefits please click here:Benefits CoxHealth

Job Description:

Job Summary
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. This position is also responsible for ongoing education of the patient care team regarding proper clinical documentation utilizing approved guidelines. Understand and utilization of ICD-10-CM and PCS coding assignment and follow Official Coding Guidelines.
Job Requirements
Education
Required: Graduate of an approved nursing program
Preferred: Bachelors Degree in Nursing
Experience
Required: 3 years acute care experience 5 years preferred
Preferred: Preferred experience in (ED ICU Neuro or Stepdown)
Skills
Ability to apply coding guidelines when reviewing documentation in the medical record.
Ability to perform computer data entry.
Ability to work with others and communicate effectively.
Licensure/Certification/Registration
Required: Registered Nursing License
Preferred: CCDS or CDIP Education Required: Graduate of an approved nursing program Preferred: Bachelors Degree in Nursing Experience Required: 3 years acute care experience 5 years preferred Preferred: Preferred experience in (ED ICU Neuro or Stepdown) Skills Ability to apply coding guidelines when reviewing documentation in the medical record. Ability to perform computer data entry. Ability to work with others and communicate effectively. Licensure/Certification/Registration Required: Registered Nursing License Preferred: CCDS or CDIP