Clinical Documentation Integrity Nurse

Intermountain Health

1d • $44 - $66 • Onsite

About The Position

The Clinical Documentation Integrity Nurse (CDI RN) utilizes clinical expertise, expert coding knowledge, and critical thinking skills to work collaboratively with Medical Directors. This position provides high-level expertise in the areas of coding and contracting, insurance regulations, and risk adjustment capitated revenue. Nurses review complex clinical provider notes and communicate with providers to meticulously identify ambiguous documentation or discrepancies between documentation and the patient's clinical presentation. This position also provides education and training to customers (physicians, mid-level providers, office staff) on clinical indicators and risk adjustment capitated revenue. Essential Functions Ensure clinical documentation is accurate, specific, complete, and compliant to reflect the severity of illness and risk of mortality of the patient. Work collaboratively with providers to identify opportunities for the accuracy and quality of chart documentation. Identify complications and co-morbid conditions, specify co-existing and causal conditions, and follow up with providers responsible for the care of the patient for appropriate documentation. Identify the need to clarify documentation in the medical record by communicating with providers face-to-face or in written communication. Stay abreast of coding guidelines, risk adjustment payment methodologies, regulatory compliance, and quality-based programs. Maintain thorough and current knowledge of clinical care and treatment options to critically assess the accuracy and appropriateness of documentation. Maintain thorough clinical knowledge of disease processes, pathophysiology, and pharmacology. Demonstrate excellent communication and interaction skills to diplomatically handle difficult, complex, and/or potentially political situations with physicians, office staff during clinic in-person on-site work, and other external and internal customers and departments. Serve as a resource for providers to educate on linking coding guidelines and medical terminology to capture opportunities. Perform other duties as assigned, including but not limited to the orientation of caregivers.

Requirements

• Bachelor’s degree in nursing (BSN) from an accredited institution (degree will be verified).
• Current RN License in state of practice.
• Demonstrated clinical nursing experience in a diverse setting.
• Demonstrated experience in clinical documentation integrity and/or outpatient coding.
• Demonstrated experience in chart reviews and/or auditing.
• Strong communication skills to effectively convey complex ideas.
• Ability to thrive in a fast-paced environment and manage multiple tasks simultaneously.
• Ability to work independently with minimal supervision.
• Proficient in using Electronic Medical Record (EMR) tools
• Must live in the greater Las Vegas Area for on site clinic days

Nice To Haves

• Five (5) years of clinical nursing experience in a diverse setting.
• Demonstrated clinical experience in ICU, primary care, admissions, and discharges.
• Proficient in Microsoft Office Suite.

Responsibilities

• Ensure clinical documentation is accurate, specific, complete, and compliant to reflect the severity of illness and risk of mortality of the patient.
• Work collaboratively with providers to identify opportunities for the accuracy and quality of chart documentation.
• Identify complications and co-morbid conditions, specify co-existing and causal conditions, and follow up with providers responsible for the care of the patient for appropriate documentation.
• Identify the need to clarify documentation in the medical record by communicating with providers face-to-face or in written communication.
• Stay abreast of coding guidelines, risk adjustment payment methodologies, regulatory compliance, and quality-based programs.
• Maintain thorough and current knowledge of clinical care and treatment options to critically assess the accuracy and appropriateness of documentation.
• Maintain thorough clinical knowledge of disease processes, pathophysiology, and pharmacology.
• Demonstrate excellent communication and interaction skills to diplomatically handle difficult, complex, and/or potentially political situations with physicians, office staff during clinic in-person on-site work, and other external and internal customers and departments.
• Serve as a resource for providers to educate on linking coding guidelines and medical terminology to capture opportunities.
• Perform other duties as assigned, including but not limited to the orientation of caregivers.

Benefits

• We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
• Intermountain Health’s PEAK program supports caregivers in the pursuit of their education goals and career aspirations by providing up-front tuition coverage paid directly to the academic institution. The program offers 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates. Caregivers are eligible to participate in PEAK on day 1 of employment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level