RN Clinical Documentation Specialist - Remote Eligible

Clinical Documentation Improvement Specialist

The mission of the Clinical Documentation Improvement Department is to, "Facilitate concise clinical documentation to appropriately reflect patient acuity, risk of mortality, and resource utilization in order to properly reflect patient care given and optimize organizational goals." This mission also supports the accurate translation of diagnoses into ICD-10 codes for patient billing and capture of quality metrics.

As a successful Clinical Documentation Improvement Specialist, you will need to have at a minimum 2-4 years of hospital acute-care or relevant clinical experience. Time in OR, ED or ICU may strengthen a candidate’s profile. Level of education may be either registered nurse with active licensure in state worked or graduate of foreign medical school with Doctor of medicine degree.

This is a fully remote position and available if you live in the following states only: AK, AL, AR, AZ, CA, CO, FL, GA, IA, ID, IN, KS, KY, MI, MN, MO, MS, NC, ND, NE, NM, NV, NY, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI & WY. This position is fully remote with travel less than 15% of the time to either a Banner corporate or hospital site. With this remote work, candidates must be self-motivated, possess moderate to strong tech skills and be able to meet daily and weekly productivity metrics. Schedule is Monday through Friday, regular business hours. You are required to work at least 75% of your shift within 7AM to 7PM AZT/MST. No holidays or weekends.

Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care.

POSITION SUMMARY This position is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position is a member of the clinical team responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the diagnostic related group (DRG), severity of illness (SOI), risk of mortality (ROM), risk adjustment, and the complexity of patient care rendered.

CORE FUNCTIONS 1. Provides subject matter expertise related to DRG, clinical documentation opportunities and requirements. Serves as an essential member of the clinical team, emphasizing their role in reviewing content of the medical record, assisting in the clarification of documentation ambiguities. Serves as the liaison between acute care coding and providers in order to capture accurate DRG, SOI, ROM, risk adjustment, reimbursement, and complexity of patient care rendered.

2. Conducts accurate and timely concurrent record reviews, recognizing opportunities for documentation improvement through specialized training and software. Utilizes available resources to formulate clinically credible and compliant provider documentation clarification (queries) aimed at improving the accuracy of the documentation process.

3. Ensures data integrity of the clinical documentation database through compliant, accurate and appropriate entries, which includes but is not limited to, accurate input of case data, correct assignment of documentation clarification types and provider responses, and ensuring precise case reconciliation with correct DRG shifts recorded.

4. Ensures the accuracy and completeness of clinical information used for measuring and reporting provider and facility outcomes (e.g., DRG assignment, hospital acquired conditions, patient safety indicators, quality of care, facility and system initiatives) while maintaining compliance with HIMS dept time requirements for coding and billing revenue cycle.

5. Educates customers through presentations and/or reports for clinicians and facility management on clinical documentation opportunities, acute care coding and reimbursement issues, as well as performance improvement methodologies.

6. This position works independently in a remote work model and has multi-facility/entity responsibility, with no direct budgetary oversight. This position requires extensive interaction with providers, HIMS professionals, nursing, and other ancillary staff.

MINIMUM QUALIFICATIONS Requires Registered Nurse (RN) license in the state of residence. Must possess a strong knowledge of clinical care as normally obtained through the completion of a bachelor’s degree in nursing. Requires two years of acute clinical care experience.

Must have the ability to interface with multiple software applications, work independently, possess demonstrated critical thinking skills, problem-solving abilities, communication and time management skills. Must demonstrate ability to work effectively in an interdisciplinary team format.

PREFERRED QUALIFICATIONS Experience with acute clinical documentation programs or coding. Certified Clinical Documentation Specialist (CCDS), Certified Documentation Integrity Practitioner (CDIP), Certified Coding Specialist (CCS) Specialist, or Certified Professional Coder (CPC). Additional related education and/or experience preferred.