Clinical Documentation Nurse

CentraCare • Saint Cloud, MN

1d • $85,987 - $128,981 • Remote

About The Position

CentraCare is looking for a qualified Clinical Documentation Nurse to join our team! This role is responsible for concurrent auditing of medical record documentation to evaluate the documentation and utilization review of services to adequately reflect care provided and resources used. Responsibilities include facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Proactively solicits clarification from physicians and clinical staff in areas where further specificity is needed in the documentation, and consults with attending physician when conflicting information appears in the medical record. Maintains documentation regarding results of audit activity and shares those with staff and management as necessary. Collects and analyzes data pertinent to documentation findings and outcomes for process improvement. This position supports the concepts and philosophies of nursing as well as sound business practices. Promotes and facilitates education to providers regarding disease processes. Communicates with appropriate healthcare team members to promote accurate and complete documentation of each patient encounter.

Requirements

• Bachelor's degree in nursing required
• Current Registered Nurse (RN) licensure in the State of Minnesota required
• Minimum of 3 years acute care experience required
• Performance improvement, quality assurance related experience is required
• Critical Thinking - must have the ability to process large amounts of information and to evaluate meaning with a rational open mind based on the evidence at hand.

Nice To Haves

• Certified Clinical Documentation Specialist National Certification as Clinical Documentation Specialist (CCDS) preferred
• National Certification as a Clinical Documentation Specialist-Outpatient (CCDS-O) preferred
• Utilization review, coding, clinical informatics, case management or critical care experience preferred

Responsibilities

• concurrent auditing of medical record documentation to evaluate the documentation and utilization review of services
• facilitation of appropriate physician documentation of care
• Proactively solicits clarification from physicians and clinical staff in areas where further specificity is needed in the documentation
• consults with attending physician when conflicting information appears in the medical record
• Maintains documentation regarding results of audit activity and shares those with staff and management as necessary
• Collects and analyzes data pertinent to documentation findings and outcomes for process improvement
• Promotes and facilitates education to providers regarding disease processes
• Communicates with appropriate healthcare team members to promote accurate and complete documentation of each patient encounter

Benefits

• Medical
• dental
• PTO
• retirement
• employee discounts
• Tuition reimbursement
• college grant programs

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees