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RN Clinical Document Specialist - Forbes Hospital - Full time

Allegheny Health Network

  • Company AHN
  • Monroeville, PA
  • Nursing
  • Full time
  • Day (United States of America)

Company :

Allegheny Health Network

Job Description : 


Improves the overall quality and completeness of medical documentation; facilitates enhancements to clinical documentation through extensive interaction with physicians, nursing staff, case managers, other patient caregivers, and medical records coding staff to ensure that the appropriate reimbursement is received for the level of service rendered to all inpatients; ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes; educates all members of the patient care team on an ongoing basis.


  • Review inpatient medical records for identified payor populations and analyze clinical information to identify areas within the medical record for potential gaps in physician documentation. (35%)
  • Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA) and/or quality measures. (35%)
  • Facilitate modifications to clinical documentation through extensive interaction with physicians, nurses and ancillary staff based on knowledge of DRG assignment, documentation strategies, and clinical documentation requirements. (10%)
  • Work collaboratively with coding professionals to assure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient's clinical status and care. (10%)
  • Educates all internal customers on compliant documentation responsibilities, coding and reimbursement issues, as well as performance improvement methodologies. (10%)
  • Performs other duties as assigned or required.



  • Current licensure as an RN.
  • 5 years in a nursing role in an acute care adult inpatient hospital setting.


  • Bachelor's Degree in Nursing
  • CCDS or CDIP certification
  • 2 years as a Clinical Documentation Specialist in an acute adult inpatient facility.
  • ICD 10 acute inpatient hospital coding experience.

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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