RN Specialist - Clinical Documentation- Full Time Pensacola, FL, United States (Hybrid) Job Description The Clinical Documentation Specialist- RN facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the clinical documentation improvement process is a key role. Responsibilities Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the clinical documentation improvement strategies. Performs accurate and timely medical record review. Recognizes opportunities for documentation improvement. Initiates clinical documentation improvement severity worksheet for inpatients. Formulates clinically credible documentation clarifications. Requests documentation clarifications as appropriate for SOI, core measures, and patient safety. Follows up timely on all cases and resolution of those cases with clinical documentation clarifications. Participates in task force meetings. Communicates with HIM coding staff and resolves discrepancies. Accurately inputs data into electronic clinical documentation improvement tool. Understands and supports clinical documentation improvement strategies. Maintains current knowledge/certification. Qualifications Associates Degree Nursing Required or Technical Diploma/Certificate Nursing Required 5 years Adult acute care experience in med/surg, critical care, emergency room, or PACU Required Licenses and Certifications Registered Nurse Licensed State of Florida or eligible compact state Required About Us Baptist Health Care is a not-for-profit health care system committed to improving the quality of life for people and communities in northwest Florida and south Alabama. The organization includes three hospitals, four medical parks, Andrews Institute for Orthopaedic & Sports Medicine, and an extensive primary and specialty care provider network. With more than 4,000 team members, Baptist Health Care is one of the largest non-governmental employers in northwest Florida. Baptist Health Care, Inc. is an Equal Opportunity Employer. BHC maintains and enforces a policy that prohibits discrimination against any workforce members or applicants for employment because of sex, race, age, color, disability, marital status, national origin, religion, genetic information, or other category protected by federal, state or local law. Certain positions may require a Level 2 Background check through AHCA. Additional information about this requirement can be found here: Florida Care Provider Background Screening Clearinghouse Job Info Job Identification 10313 Job Category Nursing - RN Posting Date 07/01/2026, 04:59 PM Locations 123 Baptist Way, Pensacola, FL, 32503, US (Hybrid) Job Schedule Full time Job Shift Day FTE 1.0 FT #J-18808-Ljbffr
RN Specialist - Clinical Documentation- Full Time • Pensacola, FL, United States
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