Clinical Documentation Nurse

CentraCare • Saint Cloud, MN

1d • Remote

About The Position

CentraCare is seeking a Clinical Documentation Nurse to concurrently audit medical record documentation and utilization review of services, evaluating whether records accurately reflect care provided and resources used. The role facilitates appropriate physician documentation to accurately represent patient severity of illness and risk of mortality. It proactively requests clarification from physicians and clinical staff when documentation needs greater specificity and consults attending physicians when conflicting information appears in the medical record.

The nurse maintains documentation of audit results and shares findings with staff and management as needed. The position collects and analyzes documentation findings and outcomes to support process improvement, promotes provider education about disease processes, and communicates with healthcare team members to support accurate and complete documentation for each patient encounter. The position supports nursing concepts and philosophies alongside sound business practices.

This is a full-time position at 80 hours every two weeks. After training, work is remote, with occasional travel to a CentraCare site required. The schedule is days, with 8-hour shifts and working hours between 6 a.m. and 5 p.m.

Requirements

• Bachelor's degree in nursing.
• Current Registered Nurse (RN) licensure in the State of Minnesota.
• At least 3 years of acute care experience.
• Performance improvement or quality assurance-related experience.
• Ability to process large amounts of information and evaluate its meaning with a rational, open mind based on the available evidence.

Nice To Haves

• National certification as a Clinical Documentation Specialist (CCDS).
• National certification as a Clinical Documentation Specialist-Outpatient (CCDS-O).
• Successful completion of the ACDIS bootcamp for Clinical Documentation Integrity (CDI).
• Completion of the ACDIS CDI Apprenticeship.
• Experience in utilization review, coding, clinical informatics, case management, or critical care.

Responsibilities

• Concurrently audit medical record documentation and utilization review of services to evaluate whether documentation reflects care provided and resources used.
• Facilitate appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality.
• Proactively seek clarification from physicians and clinical staff when further documentation specificity is needed.
• Consult with attending physicians when conflicting information appears in the medical record.
• Maintain documentation of audit activity results and share results with staff and management as necessary.
• Collect and analyze data about documentation findings and outcomes for process improvement.
• Promote and facilitate provider education regarding disease processes.
• Communicate with appropriate healthcare team members to promote accurate and complete documentation of each patient encounter.
• Support nursing concepts and philosophies as well as sound business practices.

Benefits

• Medical benefits
• Dental benefits
• PTO
• Retirement benefits
• Employee discounts
• Tuition reimbursement
• College grant programs

What This Job Offers

• Job Type: Full-time