Southern NH Health System - RN Clinical Documentation Specialist - Revenue Cycle - Full Time

Full time, 40 hours/week, Days (Hybrid) - Office hours in Nashua, NH 

Who We Are:

Southern New Hampshire Health has been a cornerstone of the region since 1893, delivering high-quality, compassionate care close to home. Anchored by Southern New Hampshire Medical Center—a 188-bed, DNV-accredited hospital in downtown Nashua with a Level III-N trauma center, Level II Special Care Nursery, and Magnet® designation for nursing excellence—we offer a full spectrum of services from primary care to advanced diagnostics and specialized treatments. Our medical staff includes over 500 providers from Foundation Medical Partners, and local practices. Foundation Medical Partners, our multi-specialty group, spans 70+ practices across southern New Hampshire and northern Massachusetts, providing coordinated, patient-centered care to thousands each year.

About the Job:

Title: RN Clinical Documentation Specialist
Department: Revenue Cycle
Reports To: Director, HIM, Coding and CDI

The RN Clinical Documentation Specialist facilitates concurrent documentation of health records to ensure accurate representation of Severity of Illness (SOI) and Risk of Mortality (ROM) for hospitalized patients, resulting in appropriate Diagnosis Related Group (DRG) assignment. This role includes educating healthcare team members on documentation practices that support resource utilization and patient acuity.

What You’ll Do:

• Utilize clinical expertise to ensure documentation reflects the appropriate level of service delivered to patients.

• Collaborate with Coding staff and Clinical Documentation Improvement (CDI) team to educate providers on accurate documentation for SOI, ROM, and core measures.

• Perform initial and follow-up medical record reviews using screening guidelines.

• Conduct concurrent reviews of inpatient admissions, assign working DRGs, and clarify documentation with providers as needed.

• Attend patient rounds and collaborate with case management to support medical necessity.

• Maintain databases, generate daily work lists, and track cases from admission through discharge.

• Analyze data for trends and identify educational opportunities for improvement.

• Stay current on coding guidelines and CDI workflows.

Who You Are / Requirements:

• Education: Associate degree in Nursing or Health Information Technology required; Bachelor’s degree in Nursing preferred.

• Licensure: Current NH RN license required; CCDS/CDIP certification preferred.

• Experience: Minimum 3 years of nursing experience in an acute care setting OR 3 years of inpatient coding experience required; utilization review/case management experience preferred.

• Knowledge & Skills:

  • Strong understanding of pathophysiology, disease processes, and CDI workflows.

  • Proficiency in MS Office and EHR systems.

  • Excellent oral and written communication skills.

  • Ability to interpret clinical data and identify documentation opportunities.

Why You’ll Love Us:

• Health, dental, prescription, and vision coverage for full-time & part-time employees

• Short-term, long-term disability, life & pet insurance

• Tuition & certification reimbursement (up to $4,000/year)

• Nursing Student Loan Paydown Program (up to $20,000)

• 403(b) Retirement savings plans with company matching

• Continuous earned time accrual

• & So much more!

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law.