Clinical Documentation Specialist - RN- Remote

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Clinical Documentation Specialist - RN- Remote

Roanoke, VA, US, 24011

Employment Status: Full time

Shift: Day/Evening

Facility: Remote Coders

Requisition Number: 145093

How You'll Help Transform Healthcare:

You're an accomplished nurse and a talented leader. Step up and join the extraordinary nurses providing extraordinary care at Carilion Clinic, a Joint Commission-accredited network that includes seven hospitals, two of which are Magnet-designated; multi-specialty physician practices; and affiliations with prestigious academic medical institutions.

Accountable for improving the overall quality and completeness of physician and NP/PA clinical documentation of diagnoses and procedures used in inpatient admissions. Facilitates clinical documentation improvement through extensive daily interaction with physicians, midlevel providers, healthcare team and coding staff to achieve timely, accurate, and complete documentation.

Provides for a complete medical record at patient discharge which accurately captures the patient's acuity and severity levels. Ensures documentation that results in accurate clinical data to measure and report outcomes which support appropriate reimbursement for the level of services rendered to the patient. Educates all members of the patient care team on clinical documentation improvement.

Concurrently reviews inpatient medical records to identify documentation opportunities:

a. Reviews all clinical documentation to assure all pertinent conditions are documented to reflect severity of illness and acuity of care;

b. Establishes the working DRG assignments. When necessary, collaborates with coding liaison to determine accurate working DRG.

c. Identifies and queries physicians, nurse practitioners, and physicians' assistants of potential clarifications related to the principal diagnoses, comorbid conditions and complications, and/or procedures based upon industry standards, hospital policy, and clinical indicators; assures physician documents their responses within the record in a compliant manner;

d. Ensures timely data entry and closure of cases in electronic database.

e. Conducts follow-up reviews to ensure points of clarification have been recorded in the patient's medical record.

A regional leader based in Roanoke, Virginia, we have been honored with the Beacon Award, recognized for renowned nursing research, and nationally ranked in U.S. News & World Report. Realize the advantages of advancing your career with an organization where you can expect supportive leadership, shared decision-making, state-of-the-art technological resources, inter-professional teamwork, and innovative learning.

What We Require:

Education: Bachelors degree required, or 8 years of equivalent experience.

Experience: 5 years of recent experience in a clinical hospital healthcare setting. Recent acute inpatient experience strongly preferred. CDI experience preferred.

Licensure, certification, and/or registration: Current licensure in Virginia as a Registered Nurse

Other Minimum Qualifications: Must demonstrate knowledge and competency in the following areas: satisfactory completion of orientation; positive interpersonal and communication skills; critical analysis skills; ability to resolve complaints/problems; customer-focused philosophy of service delivery; ability and willingness to work as an integral member of a multi-disciplinary team; demonstrate ability to use technology and appropriate software to support daily activities.

About Carilion

Below are our core values that we strive to embody and expect of all our team members:

Collaboration: Working together with purpose to achieve shared goals.

Commitment: Unwavering in our quest for exceptional quality and service.

Compassion: Putting heart into everything we do.

Courage: Doing what's right for our patients without question.

Curiosity: Fostering creativity and innovation in our pursuit of excellence.

Requisition Number: 145093

Employment Status: Full time

Location: Remote Coders

Shift: Day/Evening

Shift Details: Monday through Friday

Recruiter: DANA E JOHNSON

Recruiter Email: dejohnson@carilionclinic.org

For more information, contact the HR Service Center at 1-800-599-2537.

Equal Opportunity Employer

Minorities/Females/Protected Veterans/Individuals with Disabilities/Sexual Orientation/Gender Identity

Carilion Clinic is a drug-free workplace.

Carilion Total Rewards

What matters to you is important to us-like benefits, rewards, and resources to improve your life. Carilion understands the importance of prioritizing your well-being to help you develop and thrive.

When you make your tomorrow with us, we'll enhance your potential to realize the best in yourself. Below are benefits available to you when you join Carilion:

• Employer Funded Pension Plan, vested after five years (Voluntary 403B)

• Comprehensive Medical, Dental, & Vision Benefits

• Flexible Work Arrangements/Schedules

• Remote Work Options

• Paid Time Off (accrued from day one)

• Onsite fitness studios and discounts to our Carilion Wellness centers

• Access to our health and wellness app, Virgin Pulse

• Discounts on childcare

• Continued education and training

Find more about Carilion Clinic's benefits by vising our Total Rewards Page.

Equal Opportunity Employer

Minorities/Females/Protected Veterans/Individuals with Disabilities/Sexual Orientation/Gender Identity

Carilion Clinic is a drug-free workplace.

Nearest Major Market: Roanoke

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