Clinical Documentation Nurse

CentraCare • Saint Cloud, MN

2d • $88,941 - $133,494 • Remote

About The Position

CentraCare is seeking a Clinical Documentation Nurse responsible for concurrent audits of medical record documentation and utilization review to ensure records accurately reflect the care provided and resources used. The role facilitates appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. It proactively seeks clarification from physicians and clinical staff when greater specificity is needed, and consults with attending physicians when conflicting information appears in the medical record.

The nurse documents audit results and shares them with staff and management as appropriate, collects and analyzes documentation findings and outcomes for process improvement, and promotes provider education regarding disease processes. The role communicates with healthcare team members to support accurate, complete documentation of each patient encounter while supporting nursing principles and sound business practices.

This is a full-time position scheduled for 80 hours every two weeks, with day shifts of eight hours between 6 a.m. and 5 p.m. The position is remote after training, with occasional travel to a CentraCare site required.

Requirements

• Bachelor's degree in nursing.
• Current Registered Nurse (RN) licensure in the State of Minnesota.
• At least 3 years of acute care experience.
• Experience related to performance improvement or quality assurance.
• Ability to process large amounts of information and evaluate meaning rationally and with an open mind based on the evidence at hand.

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

• Conduct concurrent audits of medical record documentation and utilization review 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 request clarification from physicians and clinical staff when documentation needs greater specificity.
• Consult with attending physicians when conflicting information appears in the medical record.
• Maintain documentation of audit results and share results with staff and management as needed.
• Collect and analyze data on documentation findings and outcomes for process improvement.
• Promote and facilitate provider education regarding disease processes.
• Communicate with appropriate healthcare team members to support accurate and complete documentation of each patient encounter.
• Support nursing concepts and philosophies as well as sound business practices.

Benefits

• Medical insurance
• Dental insurance
• Paid time off (PTO)
• Retirement benefits
• Employee discounts
• Tuition reimbursement
• College grant programs

What This Job Offers

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