RN - Clinical Documentation Specialist - Day Shift
Company: ChristianaCare
Location: Newark
Posted on: January 15, 2026
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Job Description:
RN Senior Clinical Documentation Specialist Day Shift (Hours:
M-F 8 hours) Hybrid position with onsite requirements. No Weekends
or Holidays! Newark, DE Christiana Care Hospital is hiring a RN
Clinical Documentation Specialist for improving the overall quality
and completeness of clinical documentation (CDI) within the
inpatient medical record. Primary Function: Responsible to ensure
that health care services are administered with quality, cost
efficiency, and within compliance, along with improving and
ensuring the overall quality, cost efficiency and completeness of
documentation within the inpatient medical record. Ensure accuracy
of documented diagnosis and support clinical indicators. Facilitate
modifications to clinical documentation through extensive
concurrent interaction with Physician Advisor, physicians, coding
staff and other members of the healthcare team to support the
appropriate reimbursement and clinical severity are captured
compliantly for the level of service rendered to all patients.
Scope, Purpose, And Frequency of Contacts: Daily contact with
Clinical Documentation Manager, HIMS/coding staff, Physician
Advisor, and intradepartmental personnel. Frequent contact with
physicians, physician's office staff, clinical, and ancillary
departmental staff. Frequent contact with HIM Coding Management
Principal Duties & Responsibilities: Concurrent review of inpatient
medical records throughout the patient’s hospitalization. Analyzes
clinical status of patient, current treatment, past medical history
and identifies potential gaps in physician documentation.
Communicate with physicians or other providers to validate
diagnoses, clinical indicators and appropriate prompts for
documentation, if necessary, either verbally or written.
Demonstrates proficient knowledge of HIMS standards of coding and
applies to ongoing evaluation of the medical record documentation.
Educates physicians and other key healthcare providers regarding
best practice clinical documentation and the need for accurate and
complete documentation in the health record. Reviews and clarify
clinical issues in the health record with the coding professionals
that would support an accurate DRG assignment, severity of illness,
and/or risk of mortality. Monitors patients progress consults with
primary physician or designee and other members of the care
delivery team at agreed-upon intervals, or more frequently, as
needed. Participates in performance improvement activities
regarding documentation improvement Maintains confidentiality of
patients/members and staff information. Attends
coding/financial/CDI educational programs and regulatory
educational programs and updates as necessary to maintain a
proficient knowledge base. Reviews all PSI encounters for
completeness and accuracy. Review outcome with Physician Advisors,
and Medical Directors, as needed. Attends daily huddles with HIMS
to address any clinical concerns Computes a working DRG to identify
the anticipated length of stay. Shared with the care team for LOS
goals. Uses Vizient data to identify documentation opportunities
and targeted physician education. Performs assigned work safely,
adhering to established departmental safety rules and practices;
reports to manager, in a timely manner, any unsafe activities,
conditions, hazards, or safety violations that may cause injury to
oneself, other employees, patients and visitors. Performs other
related duties as required Education and Experience Requirements:
DE RN licensed or Compact State. Minimum of 3 years recent
experience as a Registered Nurse in acute care, adult care setting
preferred. RN experience in Cardiac, Critical Care, Med-Surg, and
Oncology experience highly desirable. Clinical Documentation, Case
Management, Performance Improvement, or Inpatient Coding experience
are highly desirable. Certified Clinical Documentation Specialist
(CCDS) is required in a year after eligibility. Knowledge, Skill,
And Ability: Extensive knowledge of medical terminology, anatomy,
physiology, pharmacology, and disease processes. Knowledge of
nursing principles, practices, and processes. Knowledge of ICD-10
nomenclature, UHDDS and general coding principles. Knowledge of
CMS, JCAHO and external regulatory and quality requirements.
Knowledge and ability to comply with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) Knowledge of
Performance Improvement Principles. Ability to work efficiently
independently. Ability to collaborate with clinicians and
administrative staff. • Ability to utilize computer applications on
various platforms. Ability to manage multiple projects with
constant shifts in priority. Ability to plan and organize work
assignments Physical Demands: Prolonged daily review of charts on
computer screen Working Conditions: Nursing Unit Environment – no
patient contact Normal Office Environment. Frequent deadline
situations Annual Compensation Range $85,862.40 - $137,384.00 This
pay rate/range represents ChristianaCare’s good faith and
reasonable estimate of compensation at the time of posting. The
actual salary within this range offered to a successful candidate
will depend on individual factors including without limitation
skills, relevant experience, and qualifications as they relate to
specific job requirements. Christiana Care Health System is an
equal opportunity employer, firmly committed to prohibiting
discrimination, whose staff is reflective of its community, and
considers qualified applicants for open positions without regard to
race, color, sex, religion, national origin, sexual orientation,
genetic information, gender identity or expression, age, veteran
status, disability, pregnancy, citizenship status, or any other
characteristic protected under applicable federal, state, or local
law.
Keywords: ChristianaCare, Newark , RN - Clinical Documentation Specialist - Day Shift, Healthcare , Newark, Delaware
