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Clinical Documentation Spec RN

Location: Aurora, CO, United States
Category: Nursing Professional
Job Type: Full Time
Job ID: 154179
Date Posted: Sep 18, 2023

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Clinical Documentation Specialist RN

This is a full-time, exempt/salaried position on UCHealth's Clinical Documentation Integrity team based in Aurora CO. This is a work-from-home position but you must reside in Colorado. Minimal travel will be required for staff meetings in Aurora.


Performs concurrent review of clinical documentation in written and electronic medical records to ensure compliant, appropriate and accurate reimbursement based on severity of patient illness, risk of mortality and level of services provided to patients. Collaborates with physicians, nursing staff, ancillary departments, and coding staff to ensure clinical documentation is compliant, complete and accurate. Provides ongoing education and support to the healthcare team in regard to clinical documentation in the medical record.

Work Schedule: Full Time Days

NOTE: A resume is required to be considered for this position.


Reviews inpatient medical records for areas of opportunity regarding clinical documentation of diagnosis and procedures to assign a working DRG for identified population. Conducts reviews and documents findings.

Identifies need to clarify documentation in records; communicates with providers to capture documentation that supports the severity of illness and risk of mortality. Conducts follow up reviews for responses to physician queries. Serves as a resource to physicians and staff.

Works with coding staff to assure documentation of diagnoses and comorbidities or complications are a complete reflection of the patient’s clinical status and care.

Maintains knowledge of requirements and guidelines to include changes/updates to practice or requirements.

Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action.


  • Minimum Required Education: Graduate of an accredited or state board of nursing approved Registered/Professional Nursing program.
  • Required Licensure/Certification: State licensure as a Registered Nurse (RN).
  • Minimum Experience: 5 years of recent clinical experience in an acute inpatient nursing unit OR current work experience that requires communication with providers, with 5 years of nursing in an acute care facility. Preferred: Critical care and MED/SURG background with the ability to assess and identify relevant acute and chronic medical conditions. CDI experience.


  • Critical care and MED/SURG background with the ability to assess and identify relevant acute and chronic medical conditions. 
  • CDI experience is highly desired for this position.
  • CDS or CDIP certification.

The pay range for this position is: $34.73 - $53.83/ hour. Pay is dependent on applicant's relevant experience.

UCHealth offers a Five Year Incentive Bonus to recognize employee’s contributions to our success in quality, patient experience, organizational growth, financial goals, and tenure with UCHealth. The bonus accumulates annually each October and is paid out in October following completion of five years’ employment.

UCHealth offers their employees a competitive and comprehensive total rewards package:

  • Full medical, dental and vision coverage
  • Retirement plans to include pension plan and 403(b) matching
  • Paid time off. Start your employment at UCHealth with PTO in your bank
  • Employer-paid life and disability insurance with additional buy-up coverage options
  • Tuition and continuing education reimbursement
  • Wellness benefits
  • 5 year incentive bonus
  • Full suite of voluntary benefits such as identity theft protection and pet insurance
  • Education benefits for employees, including the opportunity to be eligible for 100% of tuition, books and fees paid for by UCHealth for specific educational degrees. Other programs may also qualify for up to $5,250 pre-paid by UCHealth or in the form of tuition reimbursement each calendar year

Loan Repayment:

UCHealth is a qualifying employer for the federal Public Service Loan Forgiveness (PSLF) program!

UCHealth provides employees with free assistance navigating the PSLF program to submit their federal student loans for forgiveness through Savi.

    At UCHealth, we do things differently

    We believe in something different: a focus on the individuality of every person. In big ways and small, we exist to improve the extraordinary lives of all those we serve. As Colorado’s largest and most innovative health care system, we as a team deliver on the commitment to provide the best possible experience for our patients and their families. We foster a true human connection and give people the freedom to live extraordinary lives. A career at UCHealth is more than a job, it’s a passion.

    Going beyond quality requires the perfect balance of talent, integrity, drive and intellectual curiosity. We are looking for individuals who recognize, like us, that the world of medicine is ever-changing and are motivated to do what is right, not what is easy. We support creativity and curiosity so that each of us can find the extraordinary qualities within ourselves. At UCHealth, we’ll do everything in our power to make sure you grow and have a meaningful career. There’s no limits to your potential here.

    Be Extraordinary. Join Us Today!

    UCHealth recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity can offer our institution. As an affirmative action/equal opportunity employer, UCHealth is committed to making all employment decisions based on valid requirements. No applicant shall be discriminated against in any terms, conditions or privileges of employment or otherwise be discriminated against because of the individual’s race, creed, color, religion, gender, national origin or ancestry, age, mental or physical disability, sexual orientation, gender identity, transgender status, genetic information or veteran status. UCHealth does not discriminate against any “qualified applicant with a disability” as defined under the Americans with Disabilities Act and will make reasonable accommodations, when they do not impose an undue hardship on the organization.

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