RN Clinical Documentation Specialist

Overview

At Augusta Health, your work matters — and so do you. Whether you're delivering direct patient care, supporting operations, or innovating behind the scenes, every role contributes to our mission of promoting wellness and healing through compassionate service. We offer more than just a job — we offer a purpose-driven career in a nationally recognized, independent health system located in Virginia’s scenic Shenandoah Valley.

Learn more about career opportunities on our Careers Page.

Our team members thrive in a supportive culture that values collaboration, integrity, and excellence. With opportunities across clinical and non-clinical areas, Augusta Health is a place where your skills make a difference, and your growth is a priority.

Why Join Augusta Health?

We believe in taking care of the people who care for our community. That’s why Augusta Health offers a comprehensive and thoughtfully designed benefits package that supports your well-being, career development, and work-life balance. Whether you're launching your career or bringing in years of experience, we provide the tools, resources, and encouragement to help empower you to reach your full potential — personally, professionally, and financially.

Explore our Benefits, current Hiring Incentives, and our Taking Care of Us initiative — which embraces Belonging, Respect, Inclusion, Diversity, Growth, and Equity (B.R.I.D.G.E.) — to see how we invest in our team members and culture.

Total Rewards & Benefits (may vary by position)

• Comprehensive insurance package including medical, dental, and vision coverage
• Retirement savings plans and financial wellness support programs
• Generous paid time off and flexible scheduling to promote work-life balance
• Career development programs including clinical ladders, shared governance, and advancement opportunities
• Personalized onboarding with dedicated preceptors and ongoing educational support
• Tuition reimbursement and access to onsite childcare
• Free onsite parking, 24/7-armed security for your safety, a Health Fitness Reimbursement Program, and an onsite credit union and pharmacy
• Competitive pay with shift/weekend differentials
• Employee discounts at the cafeteria, gift shop, pharmacy, and local entertainment venues (i.e., movie tickets)

Full details are available on our Benefits Page.

Job Summary

This position plays a critical role in supporting Augusta Health’s mission and advancing departmental goals through measurable performance indicators and service excellence. This position contributes to a collaborative, patient-centered environment and helps drive outcomes aligned with organizational priorities.

The RN Clinical Documentation Specialist is accountable for improving the overall quality and completeness of physician and NP/PA clinical documentation of diagnoses and procedures using terminology integral to HIPAA-related transaction sets, primarily in inpatient and observation admissions. Facilitates clinical documentation improvement through extensive daily interaction with physicians, caregivers, care management and coding staff to achieve timely, accurate, and complete documentation. Provides for and ensures a complete medical record at patient discharge which accurately captures the patient's acuity and severity levels. Ensures documentation that results in accurate clinical data to measure and report outcomes which support appropriate reimbursement for the level of service rendered to the patient. Educates all members of the patient care team on clinical documentation improvement.

Essential Job Duties

Concurrently reviews inpatient medical records to identify documentation opportunities

• Reviews all clinical documentation to assure all pertinent conditions are documented to reflect severity of illness and acuity of care.
• Establishes the working DRG assignments. When necessary, collaborates with coding liaison to determine accurate working DRG.
• Identifies and queries physicians, nurse practitioners and physicians' assistants of potential clarifications related to the principal diagnoses, comorbid conditions, complications, present on admission status, and/or procedures based upon industry standards, hospital policy, and clinical indicators.
• Conducts follow-up reviews to ensure physicians document their responses in the records in a compliant and timely manner.
• Ensures timely data entry and closure of cases in electronic database.
• Maintains established productivity and quality standards.

Communicates with physicians regarding documentation issues to ensure immediate resolution

• Confers with physician on completeness, timeliness and appropriateness of clinical documentation.
• Provides physicians with guidelines on complete and timely documentation.
• Implements appropriate and timely referrals to physician advisers.
• Participates in resolving physician documentation issues and keeps management informed of unresolved issues.

Generates Physician Queries

• Utilizes Operational Database to generate clinically appropriate queries.
• Makes recommendations for changes to established query forms based on physician feedback and/or tracking data.
• Positively impacts the retrospective query rates through the effectiveness of the concurrent query generation.

Educates physicians and caregivers on the importance of complete and accurate clinical documentation as it relates to patient acuity, severity of illness, physician profiling/scorecards/core measures, and regulatory and reimbursement guidelines

• Utilizes dashboard data to advise and assist in development of documentation education programs.
• Participates in meetings with physicians to discuss patient care documentation trends and improvement opportunities.
• Identifies educational opportunities with other caregivers and support personnel.

Assesses improvement in the quality of clinical documentation for area of responsibility.

• Monitors results of interactions and follows up with queries until resolution.
• Collects data showing activities performed and improvements made.
• Identifies process improvement opportunities related to clinical documentation.
• Prepares administrative and clinical statistical reports as requested.
• Demonstrates the DRG/Case Mix impact of the CDCI program.

Adheres to all federal, state and hospital policies relating to medical records.

• Assures adherence to federal regulations regarding medical record documentation.
• Assures adherence to state and Quality Improvement Organization (QIO) regulations regarding
  medical record documentation.

Required Qualifications

• Education: Associates Degree in Nursing
• Licensure/Certification: Current and valid Registered Nurse license in the Commonwealth of Virginia or from a state that is part of a Compact agreement with Virginia
• Experience: 
  • Three or more years as Inpatient RN (with BSN)
  • Five or more years as Inpatient RN (without BSN)
  • Diverse bedside nursing experience.
• Driver's License: N/A
• Eligibility to work in the United States and meet Virginia state employment requirements

Preferred Qualifications

• Education: Bachelor of Science in Nursing (BSN)
• Licensure/Certification: None
• Experience:
  • Five or more years as Inpatient RN
  • Previous Clinical Documentation Specialist experience.
• Prior experience in a hospital, healthcare system, or related service-oriented environment
• Familiarity with Augusta Health’s systems, workflows, or organizational culture is a plus

Competencies, Knowledge, Skills and Abilities

• Positive interpersonal and communication skills.
• Critical analysis skills
• Ability to resolve complaints/problems
• Ability and willingness to work as an integral member of a multi-disciplinary
  team
• Computer literacy

About Augusta Health

Augusta Health is an independent, nonprofit, mission-driven health system located in Fishersville, Virginia, in the heart of the Shenandoah Valley. We offer a full continuum of inpatient and outpatient services, including Augusta Medical Center—a 255-bed facility—and Augusta Medical Group, which operates 40 practice locations and four urgent care centers. Our commitment to excellence, innovation, and compassionate care makes Augusta Health a leading employer and healthcare provider in the region.

Discover more about our history, values, and community impact on our About Us Page.

Equal Opportunity Statement

Augusta Health recruits, hires, and promotes qualified candidates for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran or military discharge status, and family medical or genetic information.

We are committed to fostering a diverse and inclusive workplace in accordance with federal and Virginia state employment laws.