St. Luke's Health System

Under general supervision, the Ambulatory Clinical Documentation Specialist- RN is responsible for facilitating improvement of clinical documentation and coding process.

• Reviews clinical documentation and facilitates modifications as needed to ensure that documentation accurately reflects the reason for admission, intensity of service rendered, risk of mortality, severity of illness, and conditions present on admission for patients, in compliance with government and other regulations. 
• Obtains appropriate clinical documentation through extensive interaction with physicians and other staff to ensure documentation reflects the level of service rendered. 
• Participates in the development and delivery of education for providers and other staff. 
• Responsible for coordination of case reviews, data collection and entry, data analysis, report preparation, presentation of data and data sharing for process improvement initiatives. 
• Performs moderately complex clinical reviews requiring independent decisions and professional experience and knowledge. 
• Benchmarks and improves clinical documentation impacting quality measurement and the organization’s financial performance and reputation. 
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and health system outcomes. 
• Reconciles DRG discrepancies collaboratively with HIM team to ensure an accurate compilation of codes sent to fiscal intermediary. 
• Other duties and responsibilities as assigned. 

- Education: Associates degree in Nursing
- Experience: 1 year relevant experience
- Licenses/Certifications: Current RN license in the state of practice

 Additional Details:

• Monday- Friday, full time, Days
• Collaborates with ambulatory providers to ensure documentation supports hierarchical condition category (HCC) capture, accurate risk adjustment, and continuity of care across patient encounters.
• Conducts proactive pre‑visit reviews to identify documentation gaps, query opportunities, and trends impacting quality metrics, population health outcomes, and value‑based care performance.
• Preferred knowledge in hierarchical condition category (HCC) and ICD-10 diagnosis coding

At St. Luke’s, caring for people in the communities we serve is our mission – and this includes our own SLHS team. We offer a robust benefits package to support our teams both professionally and personally. In addition to a competitive salary and retirement plans, we ensure our team feels supported in their benefits beyond the typical medical, dental, and vision offerings. We care about you and have fantastic financial and physical wellness options, such as: on-site massages, on-site counseling via our Employee Assistance Program, access to the Personify Health Wellness tool, as well as other formal training and career development offerings to ensure you are meeting your career goals.

St. Luke’s is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.

*Please note: this posting is not reflective of all job duties and responsibilities and is intended to provide an overview to job seekers.