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Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

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Tucson Medical Center

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Location:
United States , Tucson

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Category:

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Contract Type:
Not provided

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Salary:

Not provided

Job Description:

Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

Job Responsibility:

  • Provides concurrent review of the clinical documentation in the medical record
  • review the medical record with a clinical lens to identify any missing or understated diagnoses
  • Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan
  • Performs a thorough chart review to determine the appropriate principal diagnosis of the patient
  • Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided
  • Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care
  • Documents findings in workflow tools, noting all key information used in the tracking process
  • Review medical record concurrently for documentation not yet in the record but supported by clinical indicators
  • Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record
  • Uses appropriate querying templates to get needed documentation
  • Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries
  • Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians
  • Use data provided by managers, directors, and consulting team to actions to identify what is working well and areas of focus
  • Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication
  • Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards
  • Performs related duties as assigned

Requirements:

  • Graduation from a qualified, nationally-accredited nursing program
  • Three (3) years of RN clinical experience in an acute care setting
  • Current RN licensure permitting work in state of Arizona
  • Extensive clinical knowledge and understanding of pathology/physiology
  • Strong critical thinking skills
  • Knowledge of age-specific patient needs and the elements of disease processes and related procedures
  • Excellent written and verbal communication skills
  • Assertive personality traits to facilitate ongoing physician communication
  • Working knowledge of inpatient admission criteria
  • Ability to work independently in a time-oriented environment
  • Ability to stand and walk in the performance of job responsibilities
  • Demonstrates knowledge of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes

Nice to have:

  • CDI experience preferred
  • CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred

Additional Information:

Job Posted:
January 11, 2026

Employment Type:
Fulltime
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