RN Clinical Document Integrity Specialist - Remote

Job Description

Description

PeaceHealth is seeking a RN Clinical Document Integrity Specialist (Remote) for a Full Time, 1.00 FTE, Variable position. The general salary range for this job opening at PeaceHealth is $48.66 - $73.00. The actual hiring rate is dependent upon several factors, including but not limited to, the job/position responsibilities, location, terms of the applicable collective bargaining agreement, education, training, work experience, seniority, work performance, etc.

This remote position requires the incumbent reside in OR, WA, AK or TX by date of hire.

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates improvement to clinical documentation through extensive interaction with key stakeholders to ensure that appropriate reimbursement is received for the service rendered. Ensures the accuracy and completeness of clinical information used for measuring and reporting outcomes. Educates all members of the patient care team on an ongoing basis.

Position Details:

• Ensures the overall accuracy, completeness and timeliness of the clinical documentation to support the coding process in attaining the appropriate Diagnosis Related Groups (DRG).

• Ensures the completeness and accuracy of the clinical documentation by formulating credible clarifications, conferring with providers to clarify clinical diagnosis terminology.

• Provides training to providers and caregivers to facilitate accuracy of clinical documentation, impact on coding and reimbursement and to improve methodologies to support data integrity.

• Reviews clinical documentation, identifies incomplete or inaccurate information for clinical relevance. Works with key stakeholders to ensure points of clarification are recorded in medical records, and appropriate DRG assignment completed to allow accurate coding and reimbursement.

• Acts as a resource for best practices in clinical documentation, impact of Medicare guidelines and facilitates educating key stakeholders.

• Participates as a member of the CDI Task Force.

• Applies knowledge of current Medicare part A and how it impacts DRG assignment to the review of clinical documentation.

• Performs other duties as assigned.

What you bring:

• Accredited School of Nursing and ability to successfully pass a clinical competency exam or Doctor of Medicine.

• Master of Science in Nursing or Bachelor's Degree preferred.

• Minimum of 3 years recent acute care (direct patient care) or Clinical Documentation experience in hospital setting, either in Intensive Care, Critical Care or Medical /Surgical.

• Experience as a Clinical Documentation Specialist in a hospital program preferred.

• Experience with JA Thomas and 3M 360 Encompass CAC software preferred.

• Knowledge of pathophysiology and disease process preferred.

• Knowledge of value-based purchasing and other quality metrics affecting the clinical documentation integrity program preferred.

• Registered Nurse In state of practice or Certified Clinical Documentation Specialist required.

Skills

• Strong verbal, written and interpersonal communication skills.

• Ability to interact effectively with providers and all levels of staff to achieve quality outcomes.

• Ability to effectively communicate clinical information.

• Ability to analyze/problem solve.

• Computer skills to include word processing, spreadsheet and data entry.

• Strong organization skills with the ability to work in a fast-paced environment independently and as part of an interdisciplinary team.

• Good critical thinking skills, able to assess, evaluate and teach.

• Working knowledge of all areas of adult medicine.

Department / Location Specific Notes

Additional Registered Nurse licensure may be required within one year of hire, for work performed in other states where PeaceHealth does business.

Working Conditions

Lifting

• Consistently operates computer and other office equipment.

• Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.

• Sedentary work.

Environmental Conditions

• Predominantly operates in an office environment.

Mental/Visual

• Ability to communicate and exchange accurate information.

• The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.

PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program.

See how PeaceHealth is committed to Inclusivity, Respect for Diversity and Cultural Humility.

For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.

PeaceHealth requires a completed Primary Vaccine Series (e.g., 2 dose monovalent Pfizer, Moderna or Novavax series or 1 dose J&J vaccine series) or be Up to Date (receiving the most recent Pfizer/Moderna bivalent vaccine/booster) for COVID-19 vaccination prior to their start date. PeaceHealth has a medical and religious exemption request process for those that are unable to receive the COVID-19 primary vaccine series due to medical/religious reasons. For caregivers that will be working in Oregon there is a personal vaccine exemption form that may be requested.