Clinical Documentation Spec

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

1669 HIM Documentation Improvement

40

8:00 AM - 4:30 PM

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 Healthcare’s Best Places to work five times.

• Named one of America’s Greatest Workplaces, Greatest Workplaces in Healthcare (2025, 2026), Greatest Workplaces for Women (2023, 2024), 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 Innovation's Top Companies to Work for in Healthcare (2025).

 

• 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: Bachelor's Degree in Nursing
◦ Experience
▪ Required: 3 year’s 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: Bachelor's Degree in Nursing ◦ Experience ▪ Required: 3 year’s 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